Provider Demographics
NPI:1497743488
Name:CUMPA, EDGARD (MD)
Entity Type:Individual
Prefix:
First Name:EDGARD
Middle Name:
Last Name:CUMPA
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 1:1745 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-6126
Mailing Address - Country:US
Mailing Address - Phone:217-243-6454
Mailing Address - Fax:217-243-1388
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:217-788-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107283Medicaid
ILK38956Medicare PIN