1144451766 NPI number — GUSTAVO GONZALEZ LISW

Table of content: GUSTAVO GONZALEZ LISW (NPI 1144451766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144451766 NPI number — GUSTAVO GONZALEZ LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
GUSTAVO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144451766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1337 GUSDORF RD STE M
Provider Second Line Business Mailing Address:
PO BOX 2238
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-7200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-758-4297
Provider Business Mailing Address Fax Number:
575-751-7237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1337 GUSDORF ROAD, SUITE M
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-6671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-4297
Provider Business Practice Location Address Fax Number:
575-751-7237
Provider Enumeration Date:
07/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I 3441 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: T 8238 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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