MEDICARE: GOPI MARA KOOSHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		NM
2	207R00000X	Internal Medicine Physician	MD2020-0169	NM

General Provider Information

NPI Number	:	1235660101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOPI MARA KOOSHAM M.D.

Provider Business Mailing Address
First Line	:	PO BOX 26666
Second Line	:	PROVIDER ENROLLMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87125-6666
Country	:	US
Telephone Number	:	505-923-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 CENTRAL AVE SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4930
Country	:	US
Telephone Number	:	505-724-6124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	06/04/2026

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