Healthcare Provider Details

I. General information

NPI: 1245752005
Provider Name (Legal Business Name): DERMATOLOGY PARTNERS OF NORTHERN NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST STE 5
SANTA FE NM
87505-4752
US

IV. Provider business mailing address

1651 GALISTEO ST. SUITE 5
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-0286
  • Fax: 505-983-0286
Mailing address:
  • Phone: 505-983-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: ANGELA HEATH
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-983-0286