Provider Demographics
NPI:1952407736
Name:QUIANZON, EDILTRODITO PAEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:EDILTRODITO
Middle Name:PAEZ
Last Name:QUIANZON
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 1:13193 CENTRAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3522
Mailing Address - Country:US
Mailing Address - Phone:909-464-9675
Mailing Address - Fax:909-590-3898
Practice Address - Street 1:13193 CENTRAL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3522
Practice Address - Country:US
Practice Address - Phone:909-464-9675
Practice Address - Fax:909-590-3898
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51122208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOC511220Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAX99935Medicare UPIN