Provider Demographics
NPI:1952180580
Name:LIWAG, EDSIL BANDUYANG
Entity Type:Individual
Prefix:
First Name:EDSIL
Middle Name:BANDUYANG
Last Name:LIWAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDSIL
Other - Middle Name:BANDUYANG
Other - Last Name:LIWAG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ADMINISTRATOR
Mailing Address - Street 1:3993 CASEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2508
Mailing Address - Country:US
Mailing Address - Phone:619-690-1022
Mailing Address - Fax:
Practice Address - Street 1:3993 CASEMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-2508
Practice Address - Country:US
Practice Address - Phone:619-690-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6002863740251E00000X
CA370804527251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health