Basic Information
| Provider Information | |||||||||
| NPI: | 1538473491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD2016-0226 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | MD2016-0226 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 79288758 | 05 | NM | MEDICAID |