Provider Demographics
NPI:1205867603
Name:ESCUDERO, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:ESCUDERO
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 1:516 E. NIZHONI BLVD
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1397
Practice Address - Street 1:516 E. NIZHONI BLVD
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1397
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM84-176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R6724Medicaid
AZ414582Medicaid
NM000R6724Medicaid
AZ414582Medicaid