Healthcare Provider Details

I. General information

NPI: 1518555648
Provider Name (Legal Business Name): GONZALO A DIAZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 N MESA ST
EL PASO TX
79912-3504
US

IV. Provider business mailing address

4305 N MESA ST STE B
EL PASO TX
79902-1124
US

V. Phone/Fax

Practice location:
  • Phone: 915-875-1801
  • Fax: 915-875-1516
Mailing address:
  • Phone: 915-779-7378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LILI HERNANDEZ
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 915-204-6989