1285697979 NPI number — ENRICO GULUA AGUAS MD

Table of content: ENRICO GULUA AGUAS MD (NPI 1285697979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285697979 NPI number — ENRICO GULUA AGUAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGUAS
Provider First Name:
ENRICO
Provider Middle Name:
GULUA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1285697979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3420 22ND PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-725-7800
Provider Business Mailing Address Fax Number:
806-723-6532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 W MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSBYTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-675-7382
Provider Business Practice Location Address Fax Number:
806-675-0152
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  J1830 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: J1830 , 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: 140334744 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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