Provider Demographics
NPI:1245772987
Name:EL PASO VASCULAR P A
Entity Type:Organization
Organization Name:EL PASO VASCULAR P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-577-8346
Mailing Address - Street 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:STE 120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-779-1716
Mailing Address - Fax:915-771-6496
Practice Address - Street 1:4532 N MESA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912
Practice Address - Country:US
Practice Address - Phone:915-577-8346
Practice Address - Fax:915-577-7932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-11
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH38162086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00679DOtherMEDICARE PTAN
TX030882701Medicaid