Healthcare Provider Details

I. General information

NPI: 1275822942
Provider Name (Legal Business Name): GARY LAVERN SIMPSON M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 SENDA ALIENTO DR 18 SENDA ALIENTO
PLACITAS NM
87043-9530
US

IV. Provider business mailing address

18 SENDA ALIENTO DR 18 SENDA ALIENTO
PLACITAS NM
87043-9530
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-3946
  • Fax:
Mailing address:
  • Phone: 505-867-3946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number79-276
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: