Healthcare Provider Details

I. General information

NPI: 1790793412
Provider Name (Legal Business Name): DENNIS M HURTADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 NM HWY 528 NE
RIO RANCHO NM
87144-7650
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-2590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24082
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL6070
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME105326
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2013-0983
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number268199-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: