Provider Demographics
NPI:1578594982
Name:GARY D GOTTFRIED MD PA
Entity Type:Organization
Organization Name:GARY D GOTTFRIED MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOTTFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-551-1304
Mailing Address - Street 1:11797 SOUTH FWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7035
Mailing Address - Country:US
Mailing Address - Phone:817-551-1304
Mailing Address - Fax:817-551-5730
Practice Address - Street 1:11797 SOUTH FWY
Practice Address - Street 2:SUITE 350
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7035
Practice Address - Country:US
Practice Address - Phone:817-551-1304
Practice Address - Fax:817-551-5730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201953102Medicaid
TX201953101Medicaid
TX0A3359Medicare PIN
B23095Medicare UPIN
TX201953102Medicaid
TX00MH02Medicare PIN