Provider Demographics
NPI:1245281682
Name:EDMUNDO RUIZ DAVILA, M.D.,INC.
Entity type:Organization
Organization Name:EDMUNDO RUIZ DAVILA, M.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-793-7555
Mailing Address - Street 1:4087 PERALTA BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4849
Mailing Address - Country:US
Mailing Address - Phone:510-793-7555
Mailing Address - Fax:510-797-5372
Practice Address - Street 1:4087 PERALTA BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4849
Practice Address - Country:US
Practice Address - Phone:510-793-7555
Practice Address - Fax:510-797-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0881663OtherCLIA #
CAD34069Medicare UPIN
CA00A374100Medicare ID - Type UnspecifiedPROVIDER #