Provider Demographics
NPI:1023052164
Name:URIBEBOTERO, GONZALO (MD)
Entity type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:URIBEBOTERO
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 1:6655 HILLCROFT ST STE 100&105
Mailing Address - Street 2:MEDAGENE CLINIC, P.A.
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 STE 105
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-4824
Practice Address - Country:US
Practice Address - Phone:713-779-1633
Practice Address - Fax:713-995-5914
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1956207Q00000X, 207ZP0102X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137927302Medicaid
TX137927302Medicaid