Provider Demographics
NPI:1265405302
Name:GOTTA, JAN A (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:A
Last Name:GOTTA
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 1:1515 E 20TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9039
Mailing Address - Country:US
Mailing Address - Phone:505-326-6400
Mailing Address - Fax:505-326-4606
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-326-6400
Practice Address - Fax:505-326-4606
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0691207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201050016OtherPRESBYTERIAN HP
CO73670375Medicaid
AZ927494Medicaid
NM10016519OtherLOVELACE
NMNM009T46OtherBCBS
NM77636554Medicaid
UTT0364Medicaid
NMP00201833OtherRR MEDICARE
CO73670375Medicaid