Provider Demographics
NPI:1093093593
Name:ANTONIO DAVALOS,M.D,,P.A.
Entity Type:Organization
Organization Name:ANTONIO DAVALOS,M.D,,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-591-4467
Mailing Address - Street 1:10201 GATEWAY BLVD W
Mailing Address - Street 2:SUITE 410
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7652
Mailing Address - Country:US
Mailing Address - Phone:915-591-4467
Mailing Address - Fax:915-590-3738
Practice Address - Street 1:10201 GATEWAY BLVD W
Practice Address - Street 2:SUITE 410
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7652
Practice Address - Country:US
Practice Address - Phone:915-591-4467
Practice Address - Fax:915-590-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3834173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089836301Medicaid
TX089836301Medicaid