Healthcare Provider Details

I. General information

NPI: 1093711087
Provider Name (Legal Business Name): DARLO G. VANDER WILT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 LOMAS BLVD NW
ALBUQUERQUE NM
87102-2073
US

IV. Provider business mailing address

718 LOMAS BLVD NW
ALBUQUERQUE NM
87102-2073
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-6464
  • Fax: 505-764-9210
Mailing address:
  • Phone: 505-843-6464
  • Fax: 505-764-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number099
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: