Healthcare Provider Details

I. General information

NPI: 1093093593
Provider Name (Legal Business Name): ANTONIO DAVALOS,M.D,,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 GATEWAY BLVD W SUITE 410
EL PASO TX
79925-7652
US

IV. Provider business mailing address

10201 GATEWAY BLVD W SUITE 410
EL PASO TX
79925-7652
US

V. Phone/Fax

Practice location:
  • Phone: 915-591-4467
  • Fax: 915-590-3738
Mailing address:
  • Phone: 915-591-4467
  • Fax: 915-590-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberF3834
License Number StateTX

VIII. Authorized Official

Name: MRS. ELVIA SAMANIEGO
Title or Position: OFFICE MANAGER
Credential:
Phone: 915-591-4467