MEDICARE: DR. LUIS VENTURA GOROSPE 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	208600000X	Surgery Physician	10249	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356377824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS VENTURA GOROSPE M.D.

Provider Business Mailing Address
First Line	:	1200 W CHEROKEE ST
Second Line	:
City	:	WAGONER
State	:	OK
Zip	:	74467-4624
Country	:	US
Telephone Number	:	918-485-1240
Fax Number	:	918-485-9701

Provider Business Practice Location Address
First Line	:	705 W QUEENS ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-1767
Country	:	US
Telephone Number	:	918-252-2800
Fax Number	:	918-252-2888

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

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	09/09/2013

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