Provider Demographics
NPI:1417911090
Name:PADRON, GUSTAVO M (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:M
Last Name:PADRON
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 2409
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2409
Mailing Address - Country:US
Mailing Address - Phone:800-550-5606
Mailing Address - Fax:985-646-0750
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1500
Practice Address - Country:US
Practice Address - Phone:409-899-7500
Practice Address - Fax:985-646-0750
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ17512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124167102Medicaid
E15400Medicare UPIN
TX124167102Medicaid
TX300048078Medicare PIN