Healthcare Provider Details

I. General information

NPI: 1275067613
Provider Name (Legal Business Name): JOSE LUIS HENAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8268
US

IV. Provider business mailing address

3821 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4679
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5752
  • Fax: 575-522-5722
Mailing address:
  • Phone: 505-998-7400
  • Fax: 505-998-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD2023-1540
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13298
License Number StateSD
# 3
Primary TaxonomyN
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: