Provider Demographics
NPI:1154356780
Name:GAMBOA, ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:GAMBOA
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 1:7000 NORTH MOPAC
Mailing Address - Street 2:# 180
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-482-0045
Mailing Address - Fax:512-476-9892
Practice Address - Street 1:7000 NORTH MOPAC
Practice Address - Street 2:#180
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-482-0045
Practice Address - Fax:512-476-9892
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33649207R00000X, 208000000X
TXM7983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202793007Medicaid
TX202793004Medicaid
TX202793006Medicaid
AZ946999Medicaid
TX202793005Medicaid
AZZ114088Medicare PIN
TX202793004Medicaid
TX308786YKXVMedicare PIN
TX308786YKXYMedicare PIN
AZI32662Medicare UPIN
TX202793006Medicaid
AZZ117029Medicare PIN
TX308786YLP2Medicare PIN
TX202793005Medicaid
AZ946999Medicaid
TXTXB122094Medicare PIN
AZZ117028Medicare PIN
AZZ122128Medicare PIN