Healthcare Provider Details

I. General information

NPI: 1790770402
Provider Name (Legal Business Name): GERARDO ESCOBEDO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 LOOP 40 WEST
MIDLAND TX
79706
US

IV. Provider business mailing address

PO BOX 61880
MIDLAND TX
79711-1880
US

V. Phone/Fax

Practice location:
  • Phone: 432-617-0181
  • Fax: 432-563-0656
Mailing address:
  • Phone: 432-617-0181
  • Fax: 432-563-0656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number02002829
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036113187
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberL4925
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: