Provider Demographics
NPI:1790770402
Name:ESCOBEDO, GERARDO (DO)
Entity Type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:
Last Name:ESCOBEDO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61880
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79711-1880
Mailing Address - Country:US
Mailing Address - Phone:432-617-0181
Mailing Address - Fax:432-563-0656
Practice Address - Street 1:10100 LOOP 40 WEST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706
Practice Address - Country:US
Practice Address - Phone:432-617-0181
Practice Address - Fax:432-563-0656
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002829207W00000X
IL036113187207W00000X
TXL4925207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157744702Medicaid
KY64092257Medicaid
IN200498170Medicaid
TX157744702Medicaid
IN200498170Medicaid