Provider Demographics
NPI:1316932817
Name:WATTERBERG, TINA M (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:WATTERBERG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:5757 HARPER DRIVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-888-5757
Practice Address - Fax:505-889-3589
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM83-152207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3103Medicaid
AZ279697Medicaid
NMNM002884OtherBC BS OF NM
NM180014480OtherRRB MEDICARE RAILROAD
AZ279697Medicaid
NM$$$$$$$$$Medicare PIN