Provider Demographics
NPI:1184688624
Name:STANLEY, EDGAR J (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:J
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N PALM CANYON DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4414
Mailing Address - Country:US
Mailing Address - Phone:760-322-7900
Mailing Address - Fax:760-322-7911
Practice Address - Street 1:1100 N PALM CANYON DR
Practice Address - Street 2:SUITE 210
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4414
Practice Address - Country:US
Practice Address - Phone:760-322-7900
Practice Address - Fax:760-322-7911
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111568207Q00000X
NY254682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I02239Medicare UPIN