Provider Demographics
NPI:1457375339
Name:GIST, ADOLPHUS V (MD)
Entity type:Individual
Prefix:
First Name:ADOLPHUS
Middle Name:V
Last Name:GIST
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 1:828 KIRKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2208
Mailing Address - Country:US
Mailing Address - Phone:214-328-0518
Mailing Address - Fax:214-328-0518
Practice Address - Street 1:828 KIRKWOOD DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-2208
Practice Address - Country:US
Practice Address - Phone:214-328-0518
Practice Address - Fax:214-328-0518
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7731207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168406007Medicaid
TX8F22557Medicare UPIN
TX168406003Medicaid
TX8C6419Medicare ID - Type Unspecified
TX168406002Medicaid
TX168406006Medicaid
TXI18914Medicare UPIN
TX168406005Medicaid
TX8C7351Medicare ID - Type Unspecified