MEDICARE: DR. ELIZA B SAN ROMAN D.O., F.A.C.N.

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	2084P0804X	Child & Adolescent Psychiatry Physician	K2583	TX

General Provider Information

NPI Number	:	1144221003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZA B SAN ROMAN D.O., F.A.C.N.

Provider Business Mailing Address
First Line	:	PO BOX 304
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-0304
Country	:	US
Telephone Number	:	505-589-1122
Fax Number	:

Provider Business Practice Location Address
First Line	:	5001 N PIEDRAS ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79930-4210
Country	:	US
Telephone Number	:	915-564-6159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	09/18/2008

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