Provider Demographics
NPI:1356384622
Name:FOOT SPECIALISTS OF EL PASO
Entity type:Organization
Organization Name:FOOT SPECIALISTS OF EL PASO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMP
Authorized Official - Phone:915-577-0744
Mailing Address - Street 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-779-1716
Mailing Address - Fax:915-779-1754
Practice Address - Street 1:1501 N MESA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4046
Practice Address - Country:US
Practice Address - Phone:915-577-0744
Practice Address - Fax:915-577-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1282213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXZ00059AH7Medicaid
5942270001Medicare NSC
TXZ00059AH7Medicaid
0059AHMedicare ID - Type Unspecified