Provider Demographics
NPI:1194707943
Name:HOOTMAN, KENT R (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:R
Last Name:HOOTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LOMAS BLVD NE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 LOMAS BLVD NE BLDG 1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2560
Practice Address - Country:US
Practice Address - Phone:505-332-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-05502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49151762Medicaid
NE10025709000Medicaid
CO34336371Medicaid
NE10025709000Medicaid
NM49151762Medicaid
G49643Medicare UPIN
NMNM302267Medicare PIN
NENA1214027Medicare PIN
CO301344Medicare PIN
COCO304406Medicare PIN
NENA1215027Medicare PIN