Healthcare Provider Details

I. General information

NPI: 1184655508
Provider Name (Legal Business Name): MARIA P GOBENCION MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/14/2008
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: 505-722-1650
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number205504
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: