Healthcare Provider Details

I. General information

NPI: 1720682008
Provider Name (Legal Business Name): GASTRO CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2020
Last Update Date: 11/26/2020
Certification Date: 11/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11621 PELLICANO DR
EL PASO TX
79936-6242
US

IV. Provider business mailing address

6321 VIA SERENA DR
EL PASO TX
79912-2661
US

V. Phone/Fax

Practice location:
  • Phone: 915-529-0020
  • Fax:
Mailing address:
  • Phone: 915-529-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL C GOROSPE
Title or Position: PRESIDENT
Credential: MD
Phone: 915-529-0020