Provider Demographics
NPI:1376129858
Name:PROKSCH, DAISY MARAVILLA (MD)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:MARAVILLA
Last Name:PROKSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 ALBERTA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2707
Mailing Address - Country:US
Mailing Address - Phone:915-215-5700
Mailing Address - Fax:
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-215-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.077554208600000X
390200000X
TXBP10081555208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program