MEDICARE: DR. MARIO NUTIS M.D.

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	207V00000X	Obstetrics & Gynecology Physician	L5854	TX
2	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	L5854	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588714596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO NUTIS M.D.

Provider Business Mailing Address
First Line	:	1150 BURGUNDY DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79907-3462
Country	:	US
Telephone Number	:	915-228-2491
Fax Number	:	915-219-4890

Provider Business Practice Location Address
First Line	:	1150 BURGUNDY DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79907-3462
Country	:	US
Telephone Number	:	915-228-2491
Fax Number	:	915-219-4890

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	05/21/2026

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