1790770402 NPI number — DR. GERARDO ESCOBEDO DO

Table of content: DR. GERARDO ESCOBEDO DO (NPI 1790770402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790770402 NPI number — DR. GERARDO ESCOBEDO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESCOBEDO
Provider First Name:
GERARDO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790770402
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79711-1880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-617-0181
Provider Business Mailing Address Fax Number:
432-563-0656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10100 LOOP 40 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-617-0181
Provider Business Practice Location Address Fax Number:
432-563-0656
Provider Enumeration Date:
09/19/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  02002829 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 036113187 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: L4925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 157744702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64092257 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200498170 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".