Healthcare Provider Details

I. General information

NPI: 1811998529
Provider Name (Legal Business Name): JAMES P GOOLSBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S SCHWARTZ AVE SUITE 101
FARMINGTON NM
87401-5925
US

IV. Provider business mailing address

407 S SCHWARTZ AVE SUITE 101
FARMINGTON NM
87401-5925
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6770
  • Fax: 505-609-6775
Mailing address:
  • Phone: 505-609-6770
  • Fax: 505-609-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberF2691
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD2004-0655
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: