Healthcare Provider Details

I. General information

NPI: 1104907591
Provider Name (Legal Business Name): TED J ESPARZA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3870 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3678
  • Fax: 505-830-6505
Mailing address:
  • Phone: 505-830-3678
  • Fax: 505-830-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2523
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: