Healthcare Provider Details

I. General information

NPI: 1780245803
Provider Name (Legal Business Name): JOSEPH WILLIAM GORVETZIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2683
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2683
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4900
  • Fax:
Mailing address:
  • Phone: 505-299-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD2025-0625
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: