Provider Demographics
NPI:1669011714
Name:EL PASO SLEEP CENTER PA
Entity Type:Organization
Organization Name:EL PASO SLEEP CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-779-7378
Mailing Address - Street 1:1016 QUINTA ANTIGUA LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-2039
Mailing Address - Country:US
Mailing Address - Phone:915-779-7378
Mailing Address - Fax:915-779-2822
Practice Address - Street 1:4305 N MESA ST STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1124
Practice Address - Country:US
Practice Address - Phone:915-779-7378
Practice Address - Fax:915-779-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081351102Medicaid