=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851326961
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN GUTTMAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 03/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 RIO BRAVO BLVD SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-873-6400
-----------------------------------------------------
Fax | 505-873-6403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26666 PHS PROVIDER ENROLLMENT
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87125-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-923-6770
-----------------------------------------------------
Fax | 505-923-5354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 82-58
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------