Provider Demographics
NPI:1376248575
Name:ERAZO MONTALVAN, GLORIA BERENICE (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:BERENICE
Last Name:ERAZO MONTALVAN
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 1:701 W. 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763
Mailing Address - Country:US
Mailing Address - Phone:469-859-2528
Mailing Address - Fax:
Practice Address - Street 1:701 W. 5TH STREET
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763
Practice Address - Country:US
Practice Address - Phone:432-703-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
BP10084978390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program