Healthcare Provider Details

I. General information

NPI: 1982918090
Provider Name (Legal Business Name): GAUDENCIO PAVIA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 MALL DR SUITE A
LAS CRUCES NM
88011-8101
US

IV. Provider business mailing address

1180 MALL DR SUITE A
LAS CRUCES NM
88011-8101
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-4344
  • Fax: 575-647-8381
Mailing address:
  • Phone: 575-523-4344
  • Fax: 575-647-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2003-0735
License Number StateNM

VIII. Authorized Official

Name: GAUDENCIO PAVIA
Title or Position: MD/OWNER
Credential: MD
Phone: 575-647-8366