1992179659 NPI number — MARY ELLEN MOORE-DOMINGUEZ

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992179659 NPI number — MARY ELLEN MOORE-DOMINGUEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE-DOMINGUEZ
Provider First Name:
MARY ELLEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
MARY ELLEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992179659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 S 24TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78539-6533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-289-7025
Provider Business Mailing Address Fax Number:
956-289-7257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S 24TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78539-6533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-289-7025
Provider Business Practice Location Address Fax Number:
956-289-7257
Provider Enumeration Date:
11/18/2015

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: 101YP2500X , with the licence number:  64939 , 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: 00R945 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 138708611 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138708613 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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