Provider Demographics
NPI:1407843162
Name:CAPULONG, EDWIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:CAPULONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWIN
Other - Middle Name:L
Other - Last Name:CAPULONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8055 MAYFIELD RD
Mailing Address - Street 2:STE 105
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-2447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3004
Practice Address - Fax:216-844-1548
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.084735208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2495894Medicaid
I13997Medicare UPIN
OHH438400Medicare PIN