MEDICARE: DR. SUDHIR R GOGU D.O., PHD, MBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	L0209	TX
2	207Q00000X	Family Medicine Physician	L0209	TX

General Provider Information

NPI Number	:	1942270400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHIR R GOGU D.O., PHD, MBA

Provider Business Mailing Address
First Line	:	104 GALLERY CIRCLE
Second Line	:	STE 114
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3330
Country	:	US
Telephone Number	:	210-481-6060
Fax Number	:	210-481-6068

Provider Business Practice Location Address
First Line	:	104 GALLERY CIRCLE
Second Line	:	SUITE 114
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3330
Country	:	US
Telephone Number	:	210-481-6060
Fax Number	:	210-481-6068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	05/19/2023

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