Basic Information
| Provider Information | |||||||||
| NPI: | 1033315411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONTRERAS | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | IVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | 160 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | 160 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | RS20070279 | NM | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | P7624 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | RS20070279 | 01 | NM | TRAINING | OTHER |