Healthcare Provider Details

I. General information

NPI: 1104111624
Provider Name (Legal Business Name): GASTON ITTAY ZYLBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N VETERANS BLVD
EAGLE PASS TX
78852-3302
US

IV. Provider business mailing address

PO BOX 1470
EAGLE PASS TX
78853-1470
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-8917
  • Fax: 830-773-6432
Mailing address:
  • Phone: 830-773-8917
  • Fax: 830-773-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP1507
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: