Provider Demographics
NPI:1003426743
Name:RUEDA MANTILLA, CARLOS ANDRES (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANDRES
Last Name:RUEDA MANTILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:ANDRES
Other - Last Name:RUEDA MANTILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3821 MASTHEAD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4679
Mailing Address - Country:US
Mailing Address - Phone:312-826-1105
Mailing Address - Fax:
Practice Address - Street 1:3821 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-998-7400
Practice Address - Fax:505-998-7741
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125075440207R00000X
NMMD2025-0400207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7S1691OtherMEDICARE