Basic Information
| Provider Information | |||||||||
| NPI: | 1629003223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIBRODO | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | FERNANDEZ | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W CENTRAL AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163224589 | ||||||||
| FaxNumber: | 3163214810 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W CENTRAL AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163224589 | ||||||||
| FaxNumber: | 3163214810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 0431540 | KS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 04-31540 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XP3100X | 04-31540 | KS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200373470C | 05 | KS | MEDICAID | 0000106013 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |