Provider Demographics
NPI:1578585873
Name:CARDONA-LOYA, OCTAVIO SR (MD,FACS)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:
Last Name:CARDONA-LOYA
Suffix:SR
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 MEDICAL CENTER CT STE 4
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6634
Mailing Address - Country:US
Mailing Address - Phone:619-421-8360
Mailing Address - Fax:619-421-7632
Practice Address - Street 1:750 MEDICAL CENTER CT STE 4
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6634
Practice Address - Country:US
Practice Address - Phone:619-421-8360
Practice Address - Fax:619-421-7632
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA831244208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA831244OtherLICENSE
CA00A312440Medicaid
CA831244OtherLICENSE
CA00A312440Medicaid