Provider Demographics
NPI:1922214519
Name:BAIDA-FRAGOSO, NICOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:BAIDA-FRAGOSO
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 1:1605 GEORGE DIETER DR STE 636
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5692
Mailing Address - Country:US
Mailing Address - Phone:915-671-1371
Mailing Address - Fax:915-219-9022
Practice Address - Street 1:1900 DENVER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3008
Practice Address - Country:US
Practice Address - Phone:915-544-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ39702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169279001Medicaid
TXTXB111914Medicare PIN
TX860134Medicare ID - Type UnspecifiedPHYSICIAN