Provider Demographics
NPI:1083619696
Name:ADVINCULA, EDGARDO G (MD)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:G
Last Name:ADVINCULA
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 1358
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76241-1358
Mailing Address - Country:US
Mailing Address - Phone:940-612-5562
Mailing Address - Fax:
Practice Address - Street 1:100 KIOWA DR W APT 103
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-9507
Practice Address - Country:US
Practice Address - Phone:940-612-5562
Practice Address - Fax:940-665-6201
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2024-09-10
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
TXF5812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100161202Medicaid
TX100161202Medicaid
TXF97506Medicare UPIN