Provider Demographics
NPI:1184623407
Name:GASIC, ANDREI C (MD)
Entity type:Individual
Prefix:
First Name:ANDREI
Middle Name:C
Last Name:GASIC
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:PO BOX 130549
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0549
Mailing Address - Country:US
Mailing Address - Phone:903-579-3931
Mailing Address - Fax:903-509-5835
Practice Address - Street 1:4701 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1219
Practice Address - Country:US
Practice Address - Phone:505-727-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT126887207RG0100X
TXH2396207RG0100X, 174400000X
NMMD2021-0949207RG0100X
ORMD219009207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2021-0949OtherSTATE LICENSE
TXH2396OtherLICENSE