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General NPI Number Information
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NPI Number | 1548265713
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Entity Type | Organization
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Legal Business Name | MILAGRO MEDICAL GROUP PC
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 09/07/2010
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Provider Practice Location Address
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Address Line | 504 ELM ST NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-2512
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Country | US
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Telephone | 505-724-2005
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Fax | 505-843-2931
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Provider Business Mailing Address
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Address Line | 314 W HOUGHTON ST
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City | SANTA FE
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State | NM
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Zip | 87505-8849
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Country | US
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Telephone | 505-577-8282
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Fax | 505-843-2931
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Authorized Official
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Title or Position | PRESIDENT - OWNER
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Name | DAVID A GONZALES
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Credential | MD
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Telephone | 505-577-8282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | PT0047621 FA0044101
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License Number State | NM
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