Provider Demographics
NPI:1972595122
Name:ENGELHARDT, DAVID EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:ENGELHARDT
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 1:631 N 13TH AVE
Mailing Address - Street 2:STE B
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4964
Mailing Address - Country:US
Mailing Address - Phone:909-931-3838
Mailing Address - Fax:909-931-3349
Practice Address - Street 1:631 N 13TH AVE
Practice Address - Street 2:STE B
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4964
Practice Address - Country:US
Practice Address - Phone:909-931-3838
Practice Address - Fax:909-931-3349
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF15956Medicare UPIN
CA00G635290Medicare ID - Type Unspecified