Provider Demographics
NPI:1508950791
Name:ANAYA, THERESA M (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:ANAYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:MSC10 5590
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2745
Practice Address - Country:US
Practice Address - Phone:505-272-2024
Practice Address - Fax:505-272-2374
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93-192208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0958074Medicaid
TX054653302Medicaid
NM06206Medicaid
MO208513101Medicaid
CAXPY184605Medicaid
UT1-Z7176Medicaid
AZ162735Medicaid
PA0015964330001Medicaid
LA1682900Medicaid
OR203955Medicaid
VA6700322Medicaid
CO91931923Medicaid
AZ162735Medicaid