Provider Demographics
NPI:1225189343
Name:AREVALO, EDWARD GUISANDE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GUISANDE
Last Name:AREVALO
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:PO BOX 270472
Mailing Address - Street 2:SUITE 113, PMB 234
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-2472
Mailing Address - Country:US
Mailing Address - Phone:858-922-3057
Mailing Address - Fax:858-300-0461
Practice Address - Street 1:3262 HOLIDAY CT
Practice Address - Street 2:SUITE 200
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0026
Practice Address - Country:US
Practice Address - Phone:858-922-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA497192084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FF873AOtherMEDICARE GROUP PTAN
FH539ZOtherMEDICARE INDIVIDUAL PTAN