Provider Demographics
NPI:1770577413
Name:MAGPANTAY, EDMUNDO DIEGO (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUNDO
Middle Name:DIEGO
Last Name:MAGPANTAY
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 1:339 WHITE BRIDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-3208
Mailing Address - Country:US
Mailing Address - Phone:615-356-6877
Mailing Address - Fax:615-356-8270
Practice Address - Street 1:339 WHITE BRIDGE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-3208
Practice Address - Country:US
Practice Address - Phone:615-356-6877
Practice Address - Fax:615-356-8270
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD7717208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4019336OtherBLUE CROSS BLUE SHIELD TN
TN3154025Medicare PIN
TN3154027Medicare PIN
TN3154026Medicare PIN
TN4019336OtherBLUE CROSS BLUE SHIELD TN
TN3154028Medicare PIN