Provider Demographics
NPI:1437194685
Name:MEDAGENE CLINIC , P.A.
Entity Type:Organization
Organization Name:MEDAGENE CLINIC , P.A.
Other - Org Name:MEDAGENE CLINIC , P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:URIBEBOTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-779-1633
Mailing Address - Street 1:6655 HILLCROFT ST
Mailing Address - Street 2:SUITE 100 & 105
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-4815
Mailing Address - Country:US
Mailing Address - Phone:713-779-1633
Mailing Address - Fax:713-995-5914
Practice Address - Street 1:6655 HILLCROFT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-4815
Practice Address - Country:US
Practice Address - Phone:713-779-1633
Practice Address - Fax:713-995-5914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1956207Q00000X, 207ZP0105X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137927302Medicaid
TX45D0965514OtherCLIA