Provider Demographics
NPI:1972674786
Name:MIDEZ, JAIME A (MD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:A
Last Name:MIDEZ
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 1:124 W CASTELLANO DR STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-6139
Mailing Address - Country:US
Mailing Address - Phone:915-490-0647
Mailing Address - Fax:915-261-1018
Practice Address - Street 1:2300 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-2240
Practice Address - Country:US
Practice Address - Phone:915-562-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111750901Medicaid
TX111750906Medicaid
TXTXB151859OtherWELLMED PTAN
TX110246291OtherMEDICARE RAILROAD
TXTXB151859OtherWELLMED PTAN
TX111750901Medicaid
TXF67254Medicare UPIN
TX111750901Medicaid