Healthcare Provider Details

I. General information

NPI: 1811127657
Provider Name (Legal Business Name): GERARDO SERGIO BRIBIESCA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W BEN WHITE BLVD B-200
AUSTIN TX
78704-7192
US

IV. Provider business mailing address

205 E UNIVERSITY AVE SUITE 200
GEORGETOWN TX
78626-6814
US

V. Phone/Fax

Practice location:
  • Phone: 877-800-5722
  • Fax:
Mailing address:
  • Phone: 512-868-1124
  • Fax: 512-868-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG5866
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: