Healthcare Provider Details

I. General information

NPI: 1477986065
Provider Name (Legal Business Name): GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 9200, AREA Y, KIRTLAND AIR FORCE BASE-EAST
ALBUQUERQUE NM
87115
US

IV. Provider business mailing address

4805 PRIME PKWY
MCHENRY IL
60050-7002
US

V. Phone/Fax

Practice location:
  • Phone: 224-238-0170
  • Fax:
Mailing address:
  • Phone: 815-363-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2011-0778
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2011-0778
License Number StateNM

VIII. Authorized Official

Name: DR. GEORGE DANIEL MINGEA
Title or Position: OWNER, PHYSICIAN
Credential:
Phone: 972-429-5809