Individual
GLENDA LOPEZ PORTILLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
401 SAN MATEO BLVD SE, ALBUQUERQUE, NM 87108-2921
(505) 462-7333
(505) 462-7440
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD2020-0767
NM
390200000X
Student in an Organized Health Care Education/Training Program
—
NM
Other
Enumeration date
04/01/2017
Last updated
06/24/2021
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