Provider Demographics
NPI:1972941813
Name:HENRIQUEZ ALVARENGA, MARIO ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:MARIO ERNESTO
Middle Name:
Last Name:HENRIQUEZ ALVARENGA
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:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3630 LAS ESTANCIAS DR SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5504
Practice Address - Country:US
Practice Address - Phone:505-462-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2021-04-27
Deactivation Date:2014-05-08
Deactivation Code:
Reactivation Date:2016-08-03
Provider Licenses
StateLicense IDTaxonomies
NMMD20160227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1972941813OtherBCBS
NM1K8582OtherMEDICARE
NM1972941813Medicaid