1093093593 NPI number — ANTONIO DAVALOS,M.D,,P.A.

Table of content: (NPI 1093093593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093093593 NPI number — ANTONIO DAVALOS,M.D,,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTONIO DAVALOS,M.D,,P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093093593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10201 GATEWAY BLVD W
Provider Second Line Business Mailing Address:
SUITE 410
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79925-7652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-591-4467
Provider Business Mailing Address Fax Number:
915-590-3738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10201 GATEWAY BLVD W
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79925-7652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-591-4467
Provider Business Practice Location Address Fax Number:
915-590-3738
Provider Enumeration Date:
08/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SAMANIEGO
Authorized Official First Name:
ELVIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
915-591-4467

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  F3834 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 089836301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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