=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497300081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINIMALLY INVASIVE SURGICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2019
-----------------------------------------------------
Last Update Date | 08/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4532 N MESA ST STE B2
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-288-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6112 N MESA ST # 6027
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-288-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | DR. JOSEPH UNGAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 575-288-5122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------