Basic Information
| Provider Information | |||||||||
| NPI: | 1831492321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELGADO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6601 MONTANA AVE | ||||||||
| Address2: | SUITE G & H | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799252155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158387604 | ||||||||
| FaxNumber: | 9157724633 | ||||||||
| Practice Location | |||||||||
| Address1: | 6601 MONTANA AVE | ||||||||
| Address2: | SUITE G & H | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799252155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158387604 | ||||||||
| FaxNumber: | 9157724633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 12/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1201863 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID | 207164901 | 05 | TX | MEDICAID |