Provider Demographics
NPI:1316076482
Name:GBALAZEH, BONIFACE (MD)
Entity type:Individual
Prefix:
First Name:BONIFACE
Middle Name:
Last Name:GBALAZEH
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 1:114 SANDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2952
Mailing Address - Country:US
Mailing Address - Phone:361-212-4806
Mailing Address - Fax:361-212-7683
Practice Address - Street 1:114 SANDSTONE CT
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2952
Practice Address - Country:US
Practice Address - Phone:361-212-4806
Practice Address - Fax:361-212-7683
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8260207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB22908Medicare UPIN
TX00EG66Medicare PIN