Healthcare Provider Details

I. General information

NPI: 1629163134
Provider Name (Legal Business Name): BARRY MATTHEW ALTENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR SUITE 101B
SANTA FE NM
87505-5459
US

IV. Provider business mailing address

1925 ASPEN DR SUITE 101B
SANTA FE NM
87505-5459
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-0794
  • Fax:
Mailing address:
  • Phone: 505-690-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number96-172
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15872
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: