Provider Demographics
NPI:1164454385
Name:CAPITULO, EDGARDO M (MD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:M
Last Name:CAPITULO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2416
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91396-2416
Mailing Address - Country:US
Mailing Address - Phone:818-882-7656
Mailing Address - Fax:818-773-9517
Practice Address - Street 1:1411 W SUNSET BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-3431
Practice Address - Country:US
Practice Address - Phone:818-882-7656
Practice Address - Fax:818-773-9517
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA43464208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A434640Medicaid
CAA85880Medicare UPIN
CA00A434640Medicaid