MEDICARE: DR. ANILA EJJIGANI MD

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	390200000X	Student in an Organized Health Care Education/Training Program	BP10051360	TX
2	208000000X	Pediatrics Physician	MD2018-0880	NM

General Provider Information

NPI Number	:	1366850216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANILA EJJIGANI MD

Provider Business Mailing Address
First Line	:	6838 MINERAL RIDGE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7693
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 COUNTRY CLUB RD STE 200
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:	575-332-4633

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

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	05/22/2019

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