Healthcare Provider Details

I. General information

NPI: 1518794635
Provider Name (Legal Business Name): GUILLERMO OMAR ORTEGA SANDOVAL SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BOB HOPE DR APT 501
EL PASO TX
79936-1629
US

IV. Provider business mailing address

1500 BOB HOPE DR APT 501
EL PASO TX
79936-1629
US

V. Phone/Fax

Practice location:
  • Phone: 915-335-3514
  • Fax:
Mailing address:
  • Phone: 915-335-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number24-452
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: