Provider Demographics
NPI:1649299942
Name:HEREDIA, GILBERTO JR (MD)
Entity type:Individual
Prefix:DR
First Name:GILBERTO
Middle Name:
Last Name:HEREDIA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:CLINICIAN SERVICES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:052-627-2155
Mailing Address - Fax:052-321-6275
Practice Address - Street 1:2929 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-839-2300
Practice Address - Fax:505-839-2303
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-10-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM98288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS8635Medicaid
NMNM009956OtherBCBS NUMBER
NMG70479Medicare UPIN