Provider Demographics
NPI:1770966699
Name:JUAREZ, EDNA MARITZA (MD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:MARITZA
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:MARITZA
Other - Last Name:JUAREZ RAMIREZ TELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3601 4TH ST
Mailing Address - Street 2:MS 9410
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-3673
Mailing Address - Fax:806-743-3560
Practice Address - Street 1:2450 S. TELSHOR BLVD.
Practice Address - Street 2:BLDG. D., SUITE 1
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-522-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2018-0039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty