Healthcare Provider Details

I. General information

NPI: 1558711846
Provider Name (Legal Business Name): ALFREDO NEVAREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

IV. Provider business mailing address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-4446
  • Fax: 505-287-5343
Mailing address:
  • Phone: 505-287-4446
  • Fax: 505-287-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2019-0669
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58019
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: