Provider Demographics
NPI:1801232236
Name:IBAY, EDGAR N (IDC)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:N
Last Name:IBAY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1992 CAMINITO DE LA CRUZ
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913
Mailing Address - Country:US
Mailing Address - Phone:760-828-3833
Mailing Address - Fax:
Practice Address - Street 1:1992 CAMINITO DE LA CRUZ
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913
Practice Address - Country:US
Practice Address - Phone:760-828-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710-1002XOtherIDC