Healthcare Provider Details

I. General information

NPI: 1023256120
Provider Name (Legal Business Name): JEREMY STRANGE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2672
US

IV. Provider business mailing address

5111 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2672
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-9900
  • Fax: 505-271-0217
Mailing address:
  • Phone: 505-271-9900
  • Fax: 505-271-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number7414873-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: