Healthcare Provider Details

I. General information

NPI: 1447381025
Provider Name (Legal Business Name): JONATHAN GIMBEL D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 SAINT MICHAELS DR
SANTA FE NM
87505-7712
US

IV. Provider business mailing address

1642 SAINT MICHAELS DR
SANTA FE NM
87505-7712
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-6891
  • Fax: 505-633-4192
Mailing address:
  • Phone: 505-670-6891
  • Fax: 505-633-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1088
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: