Provider Demographics
NPI:1215931878
Name:PRIETO, JOSE JR (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:PRIETO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11040 VISTA DEL SOL DR STE C
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4314
Mailing Address - Country:US
Mailing Address - Phone:915-591-7704
Mailing Address - Fax:915-591-7734
Practice Address - Street 1:11040 VISTA DEL SOL DR STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4314
Practice Address - Country:US
Practice Address - Phone:915-591-7704
Practice Address - Fax:915-591-7734
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6249208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0924086-01Medicaid
TX092408607Medicaid
TX092408606Medicaid
TX092408606Medicaid
TX092408607Medicaid
TX8L20198Medicare PIN