=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326261249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EL PASO SLEEP DISORDER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 N MESA ST STE B
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79902-1124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-779-7378
-----------------------------------------------------
Fax | 915-779-2822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1016 QUINTA ANTIGUA LN
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-779-7378
-----------------------------------------------------
Fax | 915-779-2822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GONZALO A DIAZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 915-779-7378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | G4109
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | G4109
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------