Provider Demographics
NPI:1174561351
Name:ONTIVEROS, MICHAEL A (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N MESA ST
Mailing Address - Street 2:STE C-1
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1538
Mailing Address - Country:US
Mailing Address - Phone:915-838-1500
Mailing Address - Fax:915-838-1700
Practice Address - Street 1:3800 N MESA ST
Practice Address - Street 2:STE C-1
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1538
Practice Address - Country:US
Practice Address - Phone:915-838-1500
Practice Address - Fax:915-838-1700
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F5089OtherMEDICARE PTAN
TX8V5180OtherBC/BS OF TEXAS
TXV00704Medicare UPIN