Provider Demographics
NPI:1104209642
Name:CINTRON, EDGARDO RAUL
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:RAUL
Last Name:CINTRON
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 1:1640 CAMINO DEL RIO N.
Mailing Address - Street 2:STE. 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-299-3113
Mailing Address - Fax:619-299-0766
Practice Address - Street 1:1640 CAMINO DEL RIO N.
Practice Address - Street 2:STE. 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-299-3113
Practice Address - Fax:619-299-0766
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2051152W00000X
CA33413-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ033252Medicaid
AZZ178244OtherMEDICARE PTAN
AZZ178239OtherMEDICARE PTAN
AZZ178240OtherMEDICARE PTAN
AZZ178243OtherMEDICARE PTAN
AZZ178242OtherMEDICARE PTAN
AZZ178241OtherMEDICARE PTAN