Healthcare Provider Details

I. General information

NPI: 1073752127
Provider Name (Legal Business Name): DARLO G VANDER WILT DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 05/21/2009
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:
Mailing address:
  • Phone: 505-843-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number099
License Number StateNM

VIII. Authorized Official

Name: DR. DARLO VANDER WILT
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 505-843-6464