Provider Demographics
NPI:1114112851
Name:NORTHSIDE OBSTETRICAL AND GYNECOLOGICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:NORTHSIDE OBSTETRICAL AND GYNECOLOGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:HUMBERTO
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-406-9911
Mailing Address - Street 1:6750 N MACARTHUR BLVD
Mailing Address - Street 2:STE 206
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2875
Mailing Address - Country:US
Mailing Address - Phone:972-406-9911
Mailing Address - Fax:
Practice Address - Street 1:6750 N MACARTHUR BLVD
Practice Address - Street 2:STE 206
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2875
Practice Address - Country:US
Practice Address - Phone:972-406-9911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0093EZOtherBLUE CROSS BLUE SHIELD
TN142412901Medicaid
TN142412901Medicaid