Basic Information
| Provider Information | |||||||||
| NPI: | 1659369395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | GUSTAVO | ||||||||
| MiddleName: | ARMANDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11040 VISTA DEL SOL DR | ||||||||
| Address2: | STE. A | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799354314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155914624 | ||||||||
| FaxNumber: | 9155919291 | ||||||||
| Practice Location | |||||||||
| Address1: | 11040 VISTA DEL SOL DR | ||||||||
| Address2: | STE. A | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799354314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155914624 | ||||||||
| FaxNumber: | 9155919291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207V00000X | J2185 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 116965801 | 05 | TX | MEDICAID |