=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104468438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY OF NEW MEXICO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2019
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 BROADWAY BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-225-2500
-----------------------------------------------------
Fax | 505-225-2025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 BROADWAY BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-225-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO / MD
-----------------------------------------------------
Name | SURAJ2252500 REDDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 505-225-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------