Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 92-42 | NM |
N | 2080P0203X | Pediatric Critical Care Doctor | 92-42 | NM |
NPI | 1154430486 |
---|---|
Provider Name | Jeffrey Dornbusch |
First Address | Albuquerque, NM 87106-4930 |
Second Address | Albuquerque, NM 87106-4930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 30/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000E2508 | (05) | NM |