Provider Demographics
NPI:1477525202
Name:GONZALEZ FELDMAN, EDGARD IVAN (MD)
Entity Type:Individual
Prefix:
First Name:EDGARD
Middle Name:IVAN
Last Name:GONZALEZ FELDMAN
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 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1412
Mailing Address - Fax:360-729-3025
Practice Address - Street 1:4465 CORDATA PKWY STE B
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8037
Practice Address - Country:US
Practice Address - Phone:360-752-5206
Practice Address - Fax:360-752-5653
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60601398207R00000X, 207RE0101X
TXN9863207R00000X
SC86429207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX306610206Medicaid
WA1477525202Medicaid
SC864292Medicaid
TX306610206Medicaid
TXTXB159700Medicare PIN
TX306610201Medicaid
TX390507YKTUMedicare PIN
OKOK404466Medicare UPIN
TX306610207Medicaid
390507YKTXMedicare PIN
TX390507YKTVMedicare PIN
TX1477525202OtherBLUE CROSS BLUE SHIELD