=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275822942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY LAVERN SIMPSON M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2011
-----------------------------------------------------
Last Update Date | 04/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 SENDA ALIENTO DR 18 SENDA ALIENTO
-----------------------------------------------------
City | PLACITAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87043-9530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-867-3946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 SENDA ALIENTO DR 18 SENDA ALIENTO
-----------------------------------------------------
City | PLACITAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87043-9530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-867-3946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 79-276
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------