Provider Demographics
NPI:1639146863
Name:SIERRA, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SIERRA
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130-PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:419-423-5206
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:145 W WALLACE ST
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-1239
Practice Address - Country:US
Practice Address - Phone:419-423-5206
Practice Address - Fax:419-423-5420
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057470207P00000X, 207Q00000X
IN01070922A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0717308Medicaid
OH0625767Medicare PIN
7139671Medicare PIN
OHSI4239583Medicare PIN
OHD97857Medicare UPIN
OH0717308Medicaid
OH4239584Medicare PIN
OHSI17380911Medicare PIN