Provider Demographics
NPI:1558465138
Name:RUIZ, EDISON (PA)
Entity Type:Individual
Prefix:MR
First Name:EDISON
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 E SAINT MARKS PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4440
Mailing Address - Country:US
Mailing Address - Phone:718-963-8533
Mailing Address - Fax:
Practice Address - Street 1:166 E SAINT MARKS PL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4440
Practice Address - Country:US
Practice Address - Phone:718-963-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010427207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology