Provider Demographics
NPI:1770554149
Name:GILDERSLEEVE, ROGER WESLEY (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:WESLEY
Last Name:GILDERSLEEVE
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 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9499
Mailing Address - Country:US
Mailing Address - Phone:505-281-5180
Mailing Address - Fax:505-281-5320
Practice Address - Street 1:12127B HWY 14 N STE 5
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9499
Practice Address - Country:US
Practice Address - Phone:505-281-5180
Practice Address - Fax:505-281-5320
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0789207Q00000X
TXM6632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG68414Medicare UPIN
NM443275YL1GMedicare UPIN
TX8F6235Medicare PIN
NM443275YMW8Medicare UPIN