Healthcare Provider Details

I. General information

NPI: 1477569184
Provider Name (Legal Business Name): GARY BOMMELAERE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 MEDICAL ARTS AVE NE MEDICAL ARTS CENTER
ALBUQUERQUE NM
87102-2708
US

IV. Provider business mailing address

1021 MEDICAL ARTS AVE NE MSC07 4240
ALBUQUERQUE NM
87102-2708
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6222
  • Fax:
Mailing address:
  • Phone: 505-272-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number73-94
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: