Basic Information
| Provider Information | |||||||||
| NPI: | 1669615944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA MAYORGA | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | GUILLERMO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARCIA | ||||||||
| OtherFirstName: | JESUS | ||||||||
| OtherMiddleName: | GUILLERMO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9601 SPUR 591 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791079606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063817080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9601 SPUR 591 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791079606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063817080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2009 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 39242 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | Q1983 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3704983-01 | 05 | TX | MEDICAID |