Basic Information
| Provider Information | |||||||||
| NPI: | 1205802642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAUBER | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221790 | ||||||||
| FaxNumber: | 5057221771 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221790 | ||||||||
| FaxNumber: | 5057221771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2006 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21711 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 199366 | 05 | AZ | MEDICAID | P00331308 | 01 | AZ | MEDICARE RAIL ROAD ID | OTHER |