Healthcare Provider Details

I. General information

NPI: 1700580016
Provider Name (Legal Business Name): ROBERT TODD DEBURLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC09 5030 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC09 5030 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8244
  • Fax: 505-272-4639
Mailing address:
  • Phone: 505-272-8244
  • Fax: 505-272-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2023-1126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: