Healthcare Provider Details

I. General information

NPI: 1255318630
Provider Name (Legal Business Name): EDWARD C. JUAREZ, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 N LEE TREVINO DR
EL PASO TX
79936-4521
US

IV. Provider business mailing address

PO BOX 12520
EL PASO TX
79913-0520
US

V. Phone/Fax

Practice location:
  • Phone: 915-590-9424
  • Fax: 915-590-9049
Mailing address:
  • Phone: 915-842-0504
  • Fax: 915-842-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURENCE JUAREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 915-842-0504