Healthcare Provider Details

I. General information

NPI: 1477221224
Provider Name (Legal Business Name): DEREK ELIAS DUPRIEST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 09/04/2021
Certification Date: 09/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 BARBARA LOOP SE
RIO RANCHO NM
87124-1000
US

IV. Provider business mailing address

408 ALBOR CIR NE
RIO RANCHO NM
87124-0834
US

V. Phone/Fax

Practice location:
  • Phone: 505-261-4782
  • Fax: 505-702-8604
Mailing address:
  • Phone: 505-261-4782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1199
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: