Healthcare Provider Details

I. General information

NPI: 1366535056
Provider Name (Legal Business Name): JUDITH S. DENINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

196 SE BROWN ST
LAKE CITY FL
32025-5913
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1253
  • Fax: 505-726-8671
Mailing address:
  • Phone: 425-330-7215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 072565L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 0041780
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: