Provider Demographics
NPI:1720018195
Name:LIN, MONIQUE GURGEL (MD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:GURGEL
Last Name:LIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:GURGEL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:635 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6551
Mailing Address - Country:US
Mailing Address - Phone:602-243-7277
Mailing Address - Fax:
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0055754207VM0101X
AZ31079207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ186017Medicaid
AL051523689OtherBLUE CROSS
AL051523690OtherBLUE CROSS
AL009962445Medicaid
AL051524608OtherBLUE CROSS
AL051523689Medicare ID - Type Unspecified
AL009970525Medicaid