MEDICARE: GARY BOMMELAERE MD

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	207N00000X	Dermatology Physician	73-94	NM

General Provider Information

NPI Number	:	1477569184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY BOMMELAERE MD

Provider Business Mailing Address
First Line	:	1021 MEDICAL ARTS AVE NE
Second Line	:	MSC07 4240
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2708
Country	:	US
Telephone Number	:	505-272-6222
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 MEDICAL ARTS AVE NE
Second Line	:	MEDICAL ARTS CENTER
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2708
Country	:	US
Telephone Number	:	505-272-6222
Fax Number	:

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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