Provider Demographics
NPI:1124033287
Name:GRITZKA, BORIS A (MD)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:A
Last Name:GRITZKA
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 1:6210 E HWY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3816 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:512-406-6266
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2288208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146600504Medicaid
TX146600503Medicaid
TX146600504Medicaid
TX146600501Medicaid
TX370020154Medicare PIN
TX146600503Medicaid
TX370020153Medicare PIN
TXTXB118996Medicare PIN
TX146600501Medicaid
TX8964M3Medicare PIN