Provider Demographics
NPI:1730186461
Name:EAST DESERT OB-GYN ASSOCIATES PA
Entity type:Organization
Organization Name:EAST DESERT OB-GYN ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DELA ROSA
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:915-594-9600
Mailing Address - Street 1:10657 VISTA DEL SOL DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4528
Mailing Address - Country:US
Mailing Address - Phone:915-594-9600
Mailing Address - Fax:915-594-9601
Practice Address - Street 1:10657 VISTA DEL SOL DR
Practice Address - Street 2:SUITE F
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4528
Practice Address - Country:US
Practice Address - Phone:915-594-9600
Practice Address - Fax:915-594-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164275301Medicaid
TX00091XMedicare PIN
TX164275301Medicaid