Healthcare Provider Details

I. General information

NPI: 1356326839
Provider Name (Legal Business Name): GARY LEE KASELONIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1219
US

IV. Provider business mailing address

PO BOX 452036
SUNRISE FL
33345-2036
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8104
  • Fax:
Mailing address:
  • Phone: 954-838-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD2004-0776
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: