Healthcare Provider Details

I. General information

NPI: 1194345397
Provider Name (Legal Business Name): BETHANY GUTFRUCHT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETHANY COHNHEIM

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO MSC 09-5040
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO MSC 09-5040
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6607
  • Fax: 505-272-8045
Mailing address:
  • Phone: 505-272-6607
  • Fax: 505-272-8045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2023-1128
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: