Healthcare Provider Details

I. General information

NPI: 1700141157
Provider Name (Legal Business Name): EDITH R. GURROLA MD, MPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

751 SOUTH BASCOM AVENUE DEPARTMENT OF EMERGENCY MEDICINE
SAN JOSE CA
95128
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1125
  • Fax: 505-841-1737
Mailing address:
  • Phone: 408-885-5111
  • Fax: 408-885-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR73247
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2017-0464
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: