Basic Information
| Provider Information | |||||||||
| NPI: | 1609363811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORROUGH | ||||||||
| FirstName: | STORM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11501 MONTGOMERY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871112796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD2021-0618 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 05 | NM | MEDICAID |