Healthcare Provider Details

I. General information

NPI: 1003894130
Provider Name (Legal Business Name): CHARLES J.S. GUIMARAES 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

1900 RED ROCK DR. REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
GALLUP NM
87301
US

IV. Provider business mailing address

1901 REDROCK DR PFS DEPT
GALLUP NM
87301-5683
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7200
  • Fax:
Mailing address:
  • Phone: 505-863-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number99-116
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: