Provider Demographics
NPI:1669910485
Name:ORDONEZ BENCOMO, DIANA VICTORIA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:VICTORIA
Last Name:ORDONEZ BENCOMO
Suffix:
Gender:F
Credentials:
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 12455
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87195-0455
Mailing Address - Country:US
Mailing Address - Phone:505-312-7296
Mailing Address - Fax:
Practice Address - Street 1:1317 ISLETA BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4035
Practice Address - Country:US
Practice Address - Phone:505-345-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2069175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist