Healthcare Provider Details

I. General information

NPI: 1174622666
Provider Name (Legal Business Name): JAMES M. WILTERDING, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 ENCINO PL NE SUITE D
ALBUQUERQUE NM
87102-2619
US

IV. Provider business mailing address

711 ENCINO PL NE SUITE D
ALBUQUERQUE NM
87102-2619
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-2244
  • Fax: 505-265-0557
Mailing address:
  • Phone: 505-265-2244
  • Fax: 505-265-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2003-0249
License Number StateNM

VIII. Authorized Official

Name: JAMES M. WILTERDING
Title or Position: OWNER
Credential: M.D.
Phone: 505-265-2244