Provider Demographics
NPI:1104153949
Name:V. GREGORY GONZABA, MD
Entity type:Organization
Organization Name:V. GREGORY GONZABA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GONZABA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-921-3867
Mailing Address - Street 1:999 E BASSE RD
Mailing Address - Street 2:SUITE # 180-420
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1801
Mailing Address - Country:US
Mailing Address - Phone:210-921-3867
Mailing Address - Fax:210-334-2851
Practice Address - Street 1:999 E BASSE RD
Practice Address - Street 2:SUITE # 180-420
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1801
Practice Address - Country:US
Practice Address - Phone:210-921-3867
Practice Address - Fax:210-334-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty