Provider Demographics
NPI:1699766816
Name:VARELA, ALFRED BASIL (MD,)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:BASIL
Last Name:VARELA
Suffix:
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 1:5547 N MESA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5422
Mailing Address - Country:US
Mailing Address - Phone:915-842-0504
Mailing Address - Fax:915-842-0448
Practice Address - Street 1:5055 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9442
Practice Address - Country:US
Practice Address - Phone:505-589-5005
Practice Address - Fax:505-589-1333
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM88-277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08151Medicaid
342700202Medicare PIN
NM08151Medicaid