Basic Information
| Provider Information | |||||||||
| NPI: | 1265412498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHISELLI | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 MURCHISON | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337465 | ||||||||
| FaxNumber: | 9155345289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 MURCHISON | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337465 | ||||||||
| FaxNumber: | 9155345289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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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 | 207X00000X | F3135 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100875702 | 05 | TX | MEDICAID |