Provider Demographics
NPI:1255631800
Name:LUZ DE LUNA MEDICAL CENTER, PLLC
Entity type:Organization
Organization Name:LUZ DE LUNA MEDICAL CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUEZADA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:915-875-1200
Mailing Address - Street 1:10657 VISTA DEL SOL DR STE E
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4504
Mailing Address - Country:US
Mailing Address - Phone:915-875-1200
Mailing Address - Fax:915-629-7719
Practice Address - Street 1:10657 VISTA DEL SOL DR STE E
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4504
Practice Address - Country:US
Practice Address - Phone:915-875-1200
Practice Address - Fax:915-629-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2835480-01Medicaid
TX2835480-03Medicaid
TX2835480-02OtherTHSTEPS MEDICAID
TX2835480-03Medicaid