Provider Demographics
NPI:1558528042
Name:MADRID, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MADRID
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 1:655 S. DOBSON RD.
Mailing Address - Street 2:SUITE B-218
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5671
Mailing Address - Country:US
Mailing Address - Phone:480-722-1180
Mailing Address - Fax:480-722-1187
Practice Address - Street 1:655 S. DOBSON RD.
Practice Address - Street 2:SUITE B-218
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5671
Practice Address - Country:US
Practice Address - Phone:480-722-1180
Practice Address - Fax:480-722-1187
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ16602208000000X
AZ16602208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ247454001Medicaid
AZ247454Medicaid
C99919Medicare UPIN
AZ247454Medicaid