Provider Demographics
NPI:1629132592
Name:DRAKE, EDWARD S (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
Last Name:DRAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 N ROSE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3840
Mailing Address - Country:US
Mailing Address - Phone:714-203-1760
Mailing Address - Fax:714-203-1765
Practice Address - Street 1:1325 N ROSE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3840
Practice Address - Country:US
Practice Address - Phone:714-203-1760
Practice Address - Fax:714-203-1765
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A5769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A5769OtherMEDICAL LICENSE
CACB212257Medicare PIN
CAE75203Medicare UPIN
CACB212256Medicare PIN