Healthcare Provider Details

I. General information

NPI: 1538147640
Provider Name (Legal Business Name): CHRISTOPHER GONZAGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
GALLUP NM
87301-5600
US

IV. Provider business mailing address

1901 REDROCK DR PFS DEPT
GALLUP NM
87301-5683
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-1820
  • Fax:
Mailing address:
  • Phone: 505-863-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number97-60
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: