Basic Information
Provider Information | |||||||||
NPI: | 1679967640 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BECERRA | ||||||||
FirstName: | JUAN | ||||||||
MiddleName: | GUILLERMO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4849 N MESA ST STE 201 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799125919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9153516600 | ||||||||
FaxNumber: | 9153516601 | ||||||||
Practice Location | |||||||||
Address1: | 1810 MURCHISON DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799022924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9152494470 | ||||||||
FaxNumber: | 9152606919 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2015 | ||||||||
LastUpdateDate: | 11/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | S1562 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QH0002X | S1562 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 400040801 | 05 | TX |   | MEDICAID |