Provider Demographics
NPI:1295053544
Name:MALDONADO, EDDIE MODESTO (BS,CMP)
Entity type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:MODESTO
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:BS,CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 W. 132ND ST.
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-978-1658
Mailing Address - Fax:
Practice Address - Street 1:503 N PCH HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2104
Practice Address - Country:US
Practice Address - Phone:310-376-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA986247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other