Basic Information
| Provider Information | |||||||||
| NPI: | 1770554149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILDERSLEEVE | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14 N STE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 12127B HWY 14 N STE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD2004-0789 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M6632 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.