Provider Demographics
NPI:1174571624
Name:SANDIGO, GUSTAVO H (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:H
Last Name:SANDIGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 JAMES COLEMAN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3109
Mailing Address - Country:US
Mailing Address - Phone:361-573-4000
Mailing Address - Fax:361-485-0684
Practice Address - Street 1:202 JAMES COLEMAN DR
Practice Address - Street 2:SUITE A
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3109
Practice Address - Country:US
Practice Address - Phone:361-573-4000
Practice Address - Fax:361-485-0684
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143698201Medicaid
TX129610508Medicaid
TX4314160OtherAETNA
TX8880M3OtherBLUE CROSS
TX89M33302OtherBCBS
TXP089M3332Medicaid
TX143698201Medicaid
TX8880M3Medicare PIN
TX080178536Medicare PIN
TX4314160OtherAETNA