Healthcare Provider Details

I. General information

NPI: 1205015310
Provider Name (Legal Business Name): AMIR HOUSHANG MANOUTCHEHRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 STATE HIGHWAY 14 N
CEDAR CREST NM
87008-9461
US

IV. Provider business mailing address

12125 STATE HIGHWAY 14 N
CEDAR CREST NM
87008-9461
US

V. Phone/Fax

Practice location:
  • Phone: 505-407-2174
  • Fax: 505-407-2174
Mailing address:
  • Phone: 505-407-2174
  • Fax: 505-407-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number87108
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: