Provider Demographics
NPI:1225196637
Name:JORGE A SIFUENTES MD PA
Entity Type:Organization
Organization Name:JORGE A SIFUENTES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIFUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:CLT,LSO,CASCC,MACP,N
Authorized Official - Phone:806-584-1672
Mailing Address - Street 1:713 DEAHL ST
Mailing Address - Street 2:
Mailing Address - City:BORGER
Mailing Address - State:TX
Mailing Address - Zip Code:79007-3522
Mailing Address - Country:US
Mailing Address - Phone:806-274-7057
Mailing Address - Fax:806-274-2531
Practice Address - Street 1:713 DEAHL ST
Practice Address - Street 2:
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-3522
Practice Address - Country:US
Practice Address - Phone:806-274-7057
Practice Address - Fax:806-274-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0922174400000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0065MQOtherBLUE CROSS BLUE SHIELD
TX178064501Medicaid
TX45D1041283OtherCLIA