MEDICARE: MEDAGENE CLINIC , P.A.

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	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	E1956	TX
2	208000000X	Pediatrics Physician	E1956	TX
3	207Q00000X	Family Medicine Physician	E1956	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	45D0965514	OTHER	TX	CLIA

General Provider Information

NPI Number	:	1437194685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDAGENE CLINIC , P.A.

Provider Business Mailing Address
First Line	:	6655 HILLCROFT ST
Second Line	:	SUITE 100 & 105
City	:	HOUSTON
State	:	TX
Zip	:	77081-4815
Country	:	US
Telephone Number	:	713-779-1633
Fax Number	:	713-995-5914

Provider Business Practice Location Address
First Line	:	6655 HILLCROFT ST
Second Line	:	SUITE 105
City	:	HOUSTON
State	:	TX
Zip	:	77081-4815
Country	:	US
Telephone Number	:	713-779-1633
Fax Number	:	713-995-5914

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GONZALO URIBEBOTERO
Credential	:	MD
Telephone Number	:	713-779-1633

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	08/05/2013

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Directions to “MEDAGENE CLINIC , P.A. ” Practice Location

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