Provider Demographics
NPI:1104824507
Name:K PAUL GERSTENBERG, D O, P A
Entity Type:Organization
Organization Name:K PAUL GERSTENBERG, D O, P A
Other - Org Name:K PAUL GERSTENBERG, D O, P A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-210-3336
Mailing Address - Street 1:2645 NALL ST
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-4707
Mailing Address - Country:US
Mailing Address - Phone:409-210-3336
Mailing Address - Fax:409-527-3969
Practice Address - Street 1:2645 NALL ST
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651
Practice Address - Country:US
Practice Address - Phone:409-210-3336
Practice Address - Fax:409-527-3969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167215601Medicaid
TX00575WMedicare ID - Type UnspecifiedGROUP
TX167215601Medicaid