Provider Demographics
NPI:1295745693
Name:ROMAN, GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:ROMAN
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 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 802
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-1150
Mailing Address - Fax:713-790-4990
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 802
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-1150
Practice Address - Fax:713-790-4990
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG43892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1295745693OtherBLUE CROSS BLUE SHIELD
TX133793303Medicaid
TXP01234694OtherMEDICARE RR
TX133793304OtherCIDC
TX133793310Medicaid
TXP00846906OtherMEDICARE RAILROAD
TX130018578Medicare PIN
TX8L12273Medicare PIN
TX133793310Medicaid
TX8L27309Medicare PIN