1356384622 NPI number — FOOT SPECIALISTS OF EL PASO

Table of content: (NPI 1356384622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356384622 NPI number — FOOT SPECIALISTS OF EL PASO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT SPECIALISTS OF EL PASO
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:
6
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:
1356384622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 GATEWAY BLVD W
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79925-3331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-779-1716
Provider Business Mailing Address Fax Number:
915-779-1754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 N MESA ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79902-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-577-0744
Provider Business Practice Location Address Fax Number:
915-577-0271
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
915-577-0744

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  1282 , 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: Z00059AH7 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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