Healthcare Provider Details

I. General information

NPI: 1386900116
Provider Name (Legal Business Name): JACK GEORGE GHABLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 SIGNAL AVE NE
ALBUQUERQUE NM
87113-2453
US

IV. Provider business mailing address

DEPT. 453 PO BOX 1000
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-2735
  • Fax: 505-856-2749
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD2017-0386
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: