Provider Demographics
NPI:1619101557
Name:FRIDAY, DWAYNE ELDRICH
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:ELDRICH
Last Name:FRIDAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CHELSEA ST
Mailing Address - Street 2:STE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-4925
Mailing Address - Country:US
Mailing Address - Phone:915-259-1390
Mailing Address - Fax:
Practice Address - Street 1:811 CHELSEA ST STE A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4925
Practice Address - Country:US
Practice Address - Phone:915-259-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3150207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX298202701Medicaid
TXB153205Medicare PIN