Healthcare Provider Details

I. General information

NPI: 1942191085
Provider Name (Legal Business Name): ZACHARY THOMAS FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC09 5040 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

5864 ERMEMIN AVE NW
ALBUQUERQUE NM
87114-5994
US

V. Phone/Fax

Practice location:
  • Phone: 702-428-8395
  • Fax:
Mailing address:
  • Phone: 702-428-8395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: