Healthcare Provider Details

I. General information

NPI: 1730172206
Provider Name (Legal Business Name): KENNETH CUDJOE DZUBEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 GATEWAY BLVD W STE 244
EL PASO TX
79925-3316
US

IV. Provider business mailing address

PO BOX 12211
EL PASO TX
79913-0211
US

V. Phone/Fax

Practice location:
  • Phone: 915-779-0676
  • Fax: 915-779-2534
Mailing address:
  • Phone: 915-779-0676
  • Fax: 915-779-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3627TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: