Basic Information
| Provider Information | |||||||||
| NPI: | 1629039623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TREJO | ||||||||
| FirstName: | OCTAVIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744127 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155777316 | ||||||||
| FaxNumber: | 9155777345 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 NORTH OREGON ST | ||||||||
| Address2: | PATHOLOGY DEPARTMENT | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155776011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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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 | 207ZC0500X | K6787 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | K6787 | TX | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 06879225 | 05 | NM | MEDICAID |