Provider Demographics
NPI:1003072620
Name:EDWARD A. RUIZ MD, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD A. RUIZ MD, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-564-9205
Mailing Address - Street 1:47110 WASHINGTON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2186
Mailing Address - Country:US
Mailing Address - Phone:760-564-9205
Mailing Address - Fax:760-771-6243
Practice Address - Street 1:47110 WASHINGTON ST STE 203
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2186
Practice Address - Country:US
Practice Address - Phone:760-564-9205
Practice Address - Fax:760-771-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-03
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104554261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA727Medicare PIN