Basic Information
| Provider Information | |||||||||
| NPI: | 1891876769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENTEZARI | ||||||||
| FirstName: | ABDOLHOSSEIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27829 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627026 | ||||||||
| FaxNumber: | 5057279276 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 JOURNAL CENTER NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623212 | ||||||||
| FaxNumber: | 5052623381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 468 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | N0484 | 05 | NM | MEDICAID |