Healthcare Provider Details

I. General information

NPI: 1619910080
Provider Name (Legal Business Name): EDWARD ROBLES MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD
GALLUP NM
87301-1337
US

IV. Provider business mailing address

PO BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1421
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number227427
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: