Provider Demographics
NPI:1356342075
Name:BORREGO, ED JOSE (MD)
Entity type:Individual
Prefix:
First Name:ED
Middle Name:JOSE
Last Name:BORREGO
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 1:5736 N MESA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5427
Mailing Address - Country:US
Mailing Address - Phone:915-842-9585
Mailing Address - Fax:915-842-9581
Practice Address - Street 1:5750 N MESA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5427
Practice Address - Country:US
Practice Address - Phone:915-842-9585
Practice Address - Fax:915-842-9581
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM06702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00336ZOtherMEDICARE PTAN
TX176353401Medicaid