Provider Demographics
NPI:1477986065
Name:GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
Entity Type:Organization
Organization Name:GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MINGEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-429-5809
Mailing Address - Street 1:4805 PRIME PKWY
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7002
Mailing Address - Country:US
Mailing Address - Phone:815-363-9500
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 9200, AREA Y, KIRTLAND AIR FORCE BASE-EAST
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87115
Practice Address - Country:US
Practice Address - Phone:224-238-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0778207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty