Provider Demographics
NPI:1174622666
Name:JAMES M. WILTERDING, M.D., LLC
Entity type:Organization
Organization Name:JAMES M. WILTERDING, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILTERDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-265-2244
Mailing Address - Street 1:711 ENCINO PL NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2619
Mailing Address - Country:US
Mailing Address - Phone:505-265-2244
Mailing Address - Fax:505-265-0557
Practice Address - Street 1:711 ENCINO PL NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2619
Practice Address - Country:US
Practice Address - Phone:505-265-2244
Practice Address - Fax:505-265-0557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0249261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61238015Medicaid
NMPROVP16828OtherMOLINA SALUD
NMNM009M95OtherBLUE CROSS BLUE SHIELD
NMPROVP16828OtherMOLINA SALUD