=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356473144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTY R. ONTIVEROS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 N MAIN ST
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-861-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2845
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88004-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-303-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD2005-0520
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------