MEDICARE: BLUEBONNET CHILD & ADOLESCENT PSYCHIATRY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0006X	Developmental - Behavioral Pediatrics Physician

General Provider Information

NPI Number	:	1134427545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET CHILD & ADOLESCENT PSYCHIATRY PA

Provider Business Mailing Address
First Line	:	5505 N MESA ST
Second Line	:	SUITE 1
City	:	EL PASO
State	:	TX
Zip	:	79912-5422
Country	:	US
Telephone Number	:	915-532-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 N MESA ST
Second Line	:	SUITE 1
City	:	EL PASO
State	:	TX
Zip	:	79912-5422
Country	:	US
Telephone Number	:	915-532-9200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NOAMI M DIAZ
Credential	:	MD
Telephone Number	:	915-532-9200

Provider Enumeration Date	:	03/09/2011
Last Update Date	:	04/22/2015

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