Healthcare Provider Details

I. General information

NPI: 1386691772
Provider Name (Legal Business Name): STEFAN H. GUTOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3991
  • Fax: 505-243-8405
Mailing address:
  • Phone: 505-242-3991
  • Fax: 505-243-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD2008-0667
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD2008-0667
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: