Provider Demographics
NPI:1457319410
Name:JASSO MAGDALENO, JUAN ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ANGEL
Last Name:JASSO MAGDALENO
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 1:1900 N OREGON ST
Mailing Address - Street 2:601
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3351
Mailing Address - Country:US
Mailing Address - Phone:915-542-0755
Mailing Address - Fax:
Practice Address - Street 1:1900 N OREGON ST
Practice Address - Street 2:601
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3351
Practice Address - Country:US
Practice Address - Phone:915-542-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK25022080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141691903Medicaid
TX141691903Medicaid