Individual
GOPI MARA-KOOSHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1100 CENTRAL AVE SE, ALBUQUERQUE, NM 87106-4930
(505) 724-6124
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD2020-0169
NM
390200000X
Student in an Organized Health Care Education/Training Program
—
NM
Other
Enumeration date
03/23/2017
Last updated
12/21/2020
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