Provider Demographics
NPI:1255318630
Name:EDWARD C. JUAREZ, MD, PA
Entity Type:Organization
Organization Name:EDWARD C. JUAREZ, MD, PA
Other - Org Name:EASTSIDE MEDICAL CARE CENTER, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-842-0504
Mailing Address - Street 1:PO BOX 12520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0520
Mailing Address - Country:US
Mailing Address - Phone:915-842-0504
Mailing Address - Fax:915-842-0448
Practice Address - Street 1:1721 N LEE TREVINO DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4521
Practice Address - Country:US
Practice Address - Phone:915-590-9424
Practice Address - Fax:915-590-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML0399Medicaid
TXCD3874OtherPALMETTO GBA
TX0858375-01Medicaid
TX00U98UMedicare PIN