Basic Information
Provider Information
NPI: 1003003971
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PEINADO FRAGOSO
FirstName: JESUS
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4800 ALBERTA AVE
Address2: DEPARTMENT OF PEDIATRICS
City: EL PASO
State: TX
PostalCode: 799052709
CountryCode: US
TelephoneNumber: 9155458826
FaxNumber:  
Practice Location
Address1: 4800 ALBERTA AVE
Address2: DEPARTMENT OF PEDIATRICS
City: EL PASO
State: TX
PostalCode: 799052709
CountryCode: US
TelephoneNumber: 9155458826
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/25/2007
LastUpdateDate: 07/25/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XBT10028142TXY Allopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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