Provider Demographics
NPI:1295729648
Name:ARDILA, EDGAR (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:ARDILA
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 1:28030 BLACKBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-5803
Mailing Address - Country:US
Mailing Address - Phone:714-692-5180
Mailing Address - Fax:
Practice Address - Street 1:11705 SLATE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5196
Practice Address - Country:US
Practice Address - Phone:951-351-1346
Practice Address - Fax:951-359-3748
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54539207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A545391Medicaid
F19330Medicare UPIN
CA00A545391Medicaid