Provider Demographics
NPI:1114550779
Name:GARCIA, EDGAR
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:GARCIA
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 1:1600 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2741
Mailing Address - Country:US
Mailing Address - Phone:580-491-3119
Mailing Address - Fax:
Practice Address - Street 1:2225 N UNION ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1555
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKV083370953175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist