Provider Demographics
NPI:1801420104
Name:SAN JOSE MOSCATI MEDICAL HOME
Entity Type:Organization
Organization Name:SAN JOSE MOSCATI MEDICAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANQUERO BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-342-6003
Mailing Address - Street 1:1200 GOLDEN KEY CIR STE 230
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-5834
Mailing Address - Country:US
Mailing Address - Phone:915-642-9220
Mailing Address - Fax:
Practice Address - Street 1:1200 GOLDEN KEY CIR STE 230
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-5834
Practice Address - Country:US
Practice Address - Phone:915-642-9220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty