Provider Demographics
NPI:1902825730
Name:IBANEZ, EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:
Last Name:IBANEZ
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 1:2609 W WOOLBRIGHT RD
Mailing Address - Street 2:STE 4 C
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-6634
Mailing Address - Country:US
Mailing Address - Phone:561-738-1770
Mailing Address - Fax:561-738-9992
Practice Address - Street 1:2609 W WOOLBRIGHT RD
Practice Address - Street 2:STE 4 C
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-6634
Practice Address - Country:US
Practice Address - Phone:561-738-1770
Practice Address - Fax:561-738-9992
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35446174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD78840Medicare UPIN
FL93946Medicare ID - Type Unspecified