Provider Demographics
NPI:1790793412
Name:HURTADO, DENNIS M (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:M
Last Name:HURTADO
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:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3777 NM HWY 528 NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7650
Practice Address - Country:US
Practice Address - Phone:505-404-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24082207Q00000X
TXL6070207Q00000X
FLME105326207Q00000X
NMMD2013-0983207Q00000X
NY268199-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL6070OtherALLOPATHIC PHYSICIAN LIC
AL24082OtherSTATE LICENSE
NY268199-1OtherSTATE LICENSE
NMMD2013-0983OtherSTATE LICENSE
E869OtherGROUP MDCR
FLME105326OtherSTATE LICENSE
NY268199-1OtherSTATE LICENSE