Provider Demographics
NPI:1942298138
Name:LOMA VISTA SURGERY PC
Entity type:Organization
Organization Name:LOMA VISTA SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-384-8181
Mailing Address - Street 1:2201 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3323
Mailing Address - Country:US
Mailing Address - Phone:719-384-8181
Mailing Address - Fax:719-384-4872
Practice Address - Street 1:2201 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3323
Practice Address - Country:US
Practice Address - Phone:719-384-8181
Practice Address - Fax:719-384-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21632208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04108080Medicaid
E73726Medicare UPIN
CO04108080Medicaid