Provider Demographics
NPI:1760485502
Name:VENEGAS, ERIC J (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:VENEGAS
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 80969
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-0969
Mailing Address - Country:US
Mailing Address - Phone:432-570-1113
Mailing Address - Fax:432-570-4260
Practice Address - Street 1:5007 PORTICO WAY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707
Practice Address - Country:US
Practice Address - Phone:432-570-1113
Practice Address - Fax:432-570-4260
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-06-19
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
TXK7934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144105701Medicaid
TXTH003OtherFIRSTCARE
TX0052GVOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX144105701Medicaid
TXTH003OtherFIRSTCARE