Provider Demographics
NPI:1508821430
Name:CALLEROS-MACIAS, JESUS EDMUNDO (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:EDMUNDO
Last Name:CALLEROS-MACIAS
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 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-6664
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-545-9795
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40474 TEMPORARY2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI20093Medicare UPIN
TX8C6598Medicare ID - Type Unspecified