Healthcare Provider Details

I. General information

NPI: 1124033287
Provider Name (Legal Business Name): BORIS A GRITZKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 S 1ST ST
AUSTIN TX
78704-7048
US

IV. Provider business mailing address

6210 E HWY 290
AUSTIN TX
78723-1142
US

V. Phone/Fax

Practice location:
  • Phone: 512-443-1311
  • Fax: 512-406-6266
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL2288
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: