Basic Information
| Provider Information | |||||||||
| NPI: | 1225063951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALBERTSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4303 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124623627 | ||||||||
| FaxNumber: | 5124623431 | ||||||||
| Practice Location | |||||||||
| Address1: | 4303 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124623627 | ||||||||
| FaxNumber: | 5124623431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | D7899 | TX | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207Q00000X | D7899 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 128530606 | 05 | TX | MEDICAID |