Provider Demographics
NPI:1619490133
Name:DWAYNE FRIDAY, M.D., PLLC
Entity Type:Organization
Organization Name:DWAYNE FRIDAY, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ZELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-259-1390
Mailing Address - Street 1:811 CHELSEA ST STE A
Mailing Address - Street 2:
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:888-824-5635
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:888-824-5635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX298202701Medicaid