Healthcare Provider Details

I. General information

NPI: 1528359148
Provider Name (Legal Business Name): ESPES EST,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 E AZTEC AVE
GALLUP NM
87301-4901
US

IV. Provider business mailing address

1070 RANCHO RD
GALLUP NM
87301-7036
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-9647
  • Fax:
Mailing address:
  • Phone: 505-870-9647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number97-60
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number97-23
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number97-23
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number97-23
License Number StateNM

VIII. Authorized Official

Name: DR. FLOR JARASA CABALLAR GONZAGA
Title or Position: ORGANIZER/MEMBER
Credential: M.D.
Phone: 505-870-9647