Healthcare Provider Details

I. General information

NPI: 1346809522
Provider Name (Legal Business Name): GREGORY JOHN CALVIN SUE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 ABERDEEN AVENUE
WHITE SANDS MISSILE RANGE NM
88002
US

IV. Provider business mailing address

1363 ABERDEEN AVENUE
WHITE SANDS MISSILE RANGE NM
88002
US

V. Phone/Fax

Practice location:
  • Phone: 575-674-3505
  • Fax: 915-742-7459
Mailing address:
  • Phone: 575-674-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0065014
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: