Provider Demographics
NPI:1760427413
Name:GERONDALE, G. GAVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:G.
Middle Name:GAVIN
Last Name:GERONDALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:GAVIN
Other - Last Name:GERONDALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4901 CALHOUN RD
Mailing Address - Street 2:ROOM 2107
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77204-2020
Mailing Address - Country:US
Mailing Address - Phone:713-743-2659
Mailing Address - Fax:713-743-6541
Practice Address - Street 1:4901 CALHOUN RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-2659
Practice Address - Fax:713-743-6541
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03469TG174400000X
TX3469TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093458003Medicaid
TX1124091-04Medicaid
TXT134132Medicare UPIN
TXTXB100500Medicare UPIN
TX00E63GMedicare UPIN