Provider Demographics
NPI:1518042498
Name:ZEVALLOS, EDWIN WERNER (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:WERNER
Last Name:ZEVALLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6915 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4901
Mailing Address - Country:US
Mailing Address - Phone:323-588-9800
Mailing Address - Fax:323-588-9866
Practice Address - Street 1:6915 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4901
Practice Address - Country:US
Practice Address - Phone:323-588-9800
Practice Address - Fax:323-588-9866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF91196Medicare UPIN