1043458268 NPI number — EDGAR ARDILA MD INC.

Table of content: (NPI 1043458268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043458268 NPI number — EDGAR ARDILA MD INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGAR ARDILA MD INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043458268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28030 BLACKBERRY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORBA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-351-1346
Provider Business Mailing Address Fax Number:
951-351-1346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11705 SLATE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92505-5196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-351-1344
Provider Business Practice Location Address Fax Number:
951-359-3748
Provider Enumeration Date:
01/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ARDILA
Authorized Official First Name:
EDGAR
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
951-534-3158

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  A54539 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A5453 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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