Provider Demographics
NPI:1427310200
Name:EGUAE, ESEOSA (MD)
Entity type:Individual
Prefix:
First Name:ESEOSA
Middle Name:
Last Name:EGUAE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W INTERSTATE 20 UNIT G22
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5871
Mailing Address - Country:US
Mailing Address - Phone:817-807-9060
Mailing Address - Fax:817-419-4505
Practice Address - Street 1:811 W INTERSTATE 20 UNIT G22
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-807-9060
Practice Address - Fax:817-419-4505
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP8241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349309001Medicaid
TX434173YNGSMedicare PIN