Provider Demographics
NPI:1053825315
Name:CALDERON, EDGAR (RD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:CALDERON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 44TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4522 44TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3140
Practice Address - Country:US
Practice Address - Phone:619-997-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-24
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86062627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered