MEDICARE: DR. MARTHA MANQUERO-BUTLER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L4556	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y0125199	OTHER	TX	DPS

General Provider Information

NPI Number	:	1255398293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTHA MANQUERO-BUTLER M.D.

Provider Business Mailing Address
First Line	:	3615 RUTHERGLEN ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79925-1416
Country	:	US
Telephone Number	:	915-772-5400
Fax Number	:	915-772-5402

Provider Business Practice Location Address
First Line	:	1316 N YARBROUGH DR
Second Line	:	STE. 1 A
City	:	EL PASO
State	:	TX
Zip	:	79925-7800
Country	:	US
Telephone Number	:	915-772-5400
Fax Number	:	915-772-5402

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	03/07/2023

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