Healthcare Provider Details

I. General information

NPI: 1770554149
Provider Name (Legal Business Name): ROGER WESLEY GILDERSLEEVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-5180
  • Fax: 505-281-5320
Mailing address:
  • Phone: 505-281-5180
  • Fax: 505-281-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2004-0789
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6632
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: