Provider Demographics
NPI:1184059578
Name:EDGAR, TIMOTHY RYAN (IDC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RYAN
Last Name:EDGAR
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 1:3883 INGRAHAM ST
Mailing Address - Street 2:APT #U309
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6433
Mailing Address - Country:US
Mailing Address - Phone:559-975-5651
Mailing Address - Fax:
Practice Address - Street 1:3883 INGRAHAM ST
Practice Address - Street 2:APT #U309
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-6433
Practice Address - Country:US
Practice Address - Phone:559-975-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD64763081710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman