Provider Demographics
NPI:1407840820
Name:PALACIOS, MARIANO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:M
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:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-3157
Mailing Address - Country:US
Mailing Address - Phone:915-577-0051
Mailing Address - Fax:915-577-0054
Practice Address - Street 1:4532 N MESA ST STE 2A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6287
Practice Address - Country:US
Practice Address - Phone:915-544-0326
Practice Address - Fax:915-544-2897
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133040903Medicaid
TX133040903Medicaid
TX85903FMedicare PIN