Provider Demographics
NPI:1164405064
Name:ROMERO, MELVIN (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:ROMERO
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 1:4600 JEFFERSON LN NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2134
Mailing Address - Country:US
Mailing Address - Phone:505-881-1229
Mailing Address - Fax:505-888-1918
Practice Address - Street 1:4600 JEFFERSON LN NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2134
Practice Address - Country:US
Practice Address - Phone:505-881-1229
Practice Address - Fax:505-888-1918
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49428861Medicaid
I07068Medicare UPIN
NM49428861Medicaid