1104209642 NPI number — DR. EDGARDO RAUL CINTRON

Table of content: DR. EDGARDO RAUL CINTRON (NPI 1104209642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104209642 NPI number — DR. EDGARDO RAUL CINTRON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CINTRON
Provider First Name:
EDGARDO
Provider Middle Name:
RAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1104209642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 CAMINO DEL RIO N.
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-299-3113
Provider Business Mailing Address Fax Number:
619-299-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 CAMINO DEL RIO N.
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-3113
Provider Business Practice Location Address Fax Number:
619-299-0766
Provider Enumeration Date:
07/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2051 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 33413-TLG , 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: 033252 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z178244 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z178239 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z178240 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z178243 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z178242 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: Z178241 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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