Healthcare Provider Details

I. General information

NPI: 1871949511
Provider Name (Legal Business Name): ELIZABETH DE LA NUBE GUADALUPE VALLEJO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MILITARY HEIGHTS PL
ROSWELL NM
88201-6407
US

IV. Provider business mailing address

2150 PENNSYLVANIA AVE NW STE 5-416
WASHINGTON DC
20037-3201
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-9110
  • Fax: 575-623-2191
Mailing address:
  • Phone: 202-677-6065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD2022-1375
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: