Provider Demographics
NPI:1245332923
Name:EDWARDS, ELLEN E (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7836
Mailing Address - Fax:
Practice Address - Street 1:15025 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3409
Practice Address - Country:US
Practice Address - Phone:858-806-7944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00728795OtherRRM
CA020A86130OtherBLUE SHIELD OF CA
CA00AX86130Medicaid
CAW20A8613AMedicare PIN
CAH49371Medicare UPIN