Provider Demographics
NPI:1558378471
Name:HALL, GARY MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARVIN
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8109 FREDERICKSBURG RD
Mailing Address - Street 2:PHYSICIAN PRACTICE SERVICES
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3311
Mailing Address - Country:US
Mailing Address - Phone:210-653-9307
Mailing Address - Fax:210-653-7014
Practice Address - Street 1:12709 TOEPPERWEIN RD
Practice Address - Street 2:STE 302
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3258
Practice Address - Country:US
Practice Address - Phone:210-653-9307
Practice Address - Fax:210-653-7014
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9523208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01124751OtherMEDICARE RAILROAD
TX110509007Medicaid
TX110509008OtherCSHCN
TX8DE710OtherBCBS
TXB153188Medicare PIN
TX110509008OtherMEDICAID CSN
TX110509007Medicaid