Provider Demographics
NPI:1639179690
Name:DEJESUS-PERDOMO, EDUARDO M (MD)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:M
Last Name:DEJESUS-PERDOMO
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 1:5746 TROWBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3341
Mailing Address - Country:US
Mailing Address - Phone:915-219-4300
Mailing Address - Fax:915-519-4300
Practice Address - Street 1:7812 GATEWAY BLVD E
Practice Address - Street 2:STE 230
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1802
Practice Address - Country:US
Practice Address - Phone:915-592-8223
Practice Address - Fax:915-592-8328
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8988207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111685702Medicaid
NM52383822Medicaid
TX8AW610OtherBC/BS OF TEXAS
TX8U6945OtherBCBS
TX111685703Medicaid
TX111685705Medicaid
TXP00371198OtherRAILROAD
TX110166787OtherMEDICARE RAILROAD
TX111685704Medicaid
TX110166787OtherMEDICARE RAILROAD
TX111685704Medicaid
TX8G3255Medicare PIN