Provider Demographics
NPI:1174583579
Name:ORELLANA, EDGAR A (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:A
Last Name:ORELLANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDGAR
Other - Middle Name:G
Other - Last Name:ORELLANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5827 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2000
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-472-9692
Practice Address - Street 1:315 S W C OWENS AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3637
Practice Address - Country:US
Practice Address - Phone:863-983-7813
Practice Address - Fax:863-983-9604
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373378500Medicaid
FL18680OtherBCBS PROVIDER #
FLF54137Medicare UPIN