Healthcare Provider Details

I. General information

NPI: 1245380773
Provider Name (Legal Business Name): ALBUQUERQUE GASTROENTEROLOGY ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OAK ST NE SUITE 1
ALBUQUERQUE NM
87106-4740
US

IV. Provider business mailing address

200 OAK ST NE SUITE 1
ALBUQUERQUE NM
87106-4740
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-5471
  • Fax: 505-766-6883
Mailing address:
  • Phone: 505-766-5471
  • Fax: 505-766-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number89141
License Number StateNM

VIII. Authorized Official

Name: VIJAY P AGARWAL
Title or Position: OWNER
Credential: MD
Phone: 505-766-5471