Healthcare Provider Details

I. General information

NPI: 1003590886
Provider Name (Legal Business Name): TAYDE ANALY CONTRERAS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

4509 WAITS AVE
FORT WORTH TX
76133-1540
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 817-412-1836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13405450-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: