Provider Demographics
NPI:1598762296
Name:HALL, GORDY SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:GORDY
Middle Name:SAMUEL
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W SUNSET RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1772
Mailing Address - Country:US
Mailing Address - Phone:210-824-4584
Mailing Address - Fax:210-805-8466
Practice Address - Street 1:430 W SUNSET RD STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1772
Practice Address - Country:US
Practice Address - Phone:210-824-4584
Practice Address - Fax:210-805-8466
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124491505OtherWELLMED MEDICAID
TX8A4638OtherWELLMED MEDICARE
C16478Medicare UPIN
TX8J3208Medicare PIN