Provider Demographics
NPI:1083624407
Name:GUADERRAMA, LAURO G (MD)
Entity Type:Individual
Prefix:
First Name:LAURO
Middle Name:G
Last Name:GUADERRAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36840
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-6840
Mailing Address - Country:US
Mailing Address - Phone:505-243-7729
Mailing Address - Fax:505-243-4804
Practice Address - Street 1:4401 MASTHEAD ST NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4327
Practice Address - Country:US
Practice Address - Phone:505-243-7729
Practice Address - Fax:505-243-4804
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-242207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14795Medicaid
NM14795Medicaid
NM345604102Medicare ID - Type UnspecifiedMEDICARE