Provider Demographics
NPI:1235127515
Name:VERA TAPIA, EDGARD MARIO (MD)
Entity Type:Individual
Prefix:MR
First Name:EDGARD
Middle Name:MARIO
Last Name:VERA TAPIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17207 JASMINE ST
Mailing Address - Street 2:2
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-780-4179
Mailing Address - Fax:760-241-4591
Practice Address - Street 1:17207 JASMINE ST
Practice Address - Street 2:2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-780-4179
Practice Address - Fax:760-241-4591
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79177207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10050B175Medicaid
CA00A791770Medicaid
CA1871734921Medicaid
CA1235127515Medicaid
CA00A791770Medicaid
NV10050B175Medicaid
CA00A791770Medicare PIN