Provider Demographics
NPI:1043458268
Name:EDGAR ARDILA MD INC.
Entity Type:Organization
Organization Name:EDGAR ARDILA MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-534-3158
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
Mailing Address - Country:US
Mailing Address - Phone:951-351-1346
Mailing Address - Fax:951-351-1346
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:951-351-1344
Practice Address - Fax:951-359-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54539207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A5453Medicaid
CA00A545391Medicare PIN