Provider Demographics
NPI:1053837948
Name:REGIDOR, EDGARDO DOMINGO
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:DOMINGO
Last Name:REGIDOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 MARENGO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1370
Mailing Address - Country:US
Mailing Address - Phone:323-409-7974
Mailing Address - Fax:
Practice Address - Street 1:1983 MARENGO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-409-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL581604163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology