Healthcare Provider Details

I. General information

NPI: 1407031040
Provider Name (Legal Business Name): GOPAL REDDY M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE STE 204
ALBUQUERQUE NM
87102-2543
US

IV. Provider business mailing address

500 WALTER ST NE STE 204
ALBUQUERQUE NM
87102-2543
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-5518
  • Fax: 505-247-8509
Mailing address:
  • Phone: 505-842-5518
  • Fax: 505-247-8509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number77-237
License Number StateNM

VIII. Authorized Official

Name: DR. GOPAL REDDY
Title or Position: PRESIDENT
Credential: MD
Phone: 505-842-5518