Provider Demographics
NPI:1144259664
Name:HARROD, C GORDON (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:GORDON
Last Name:HARROD
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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:1720 OSAGE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2090
Practice Address - Country:US
Practice Address - Phone:316-789-8222
Practice Address - Fax:316-789-8449
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10062OtherPHS
KS051670OtherBCBS
KS10030OtherHPK
KS12264066OtherMULTIPLAN
KS16980OtherCOVENTRY
KS10062OtherPHS
G61051Medicare UPIN