Basic Information
Provider Information | |||||||||
NPI: | 1265405302 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOTTA | ||||||||
FirstName: | JAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 E 20TH ST | ||||||||
Address2: | SUITE A | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874019039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053266400 | ||||||||
FaxNumber: | 5053264606 | ||||||||
Practice Location | |||||||||
Address1: | 801 W MAPLE ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874015630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053266400 | ||||||||
FaxNumber: | 5053264606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 12/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD2004-0691 | NM | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 201050016 | 01 | NM | PRESBYTERIAN HP | OTHER | 73670375 | 05 | CO |   | MEDICAID | 927494 | 05 | AZ |   | MEDICAID | 10016519 | 01 | NM | LOVELACE | OTHER | NM009T46 | 01 | NM | BCBS | OTHER | 77636554 | 05 | NM |   | MEDICAID | T0364 | 05 | UT |   | MEDICAID | P00201833 | 01 | NM | RR MEDICARE | OTHER |