Provider Demographics
NPI:1982602298
Name:EDILLON, EDWIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:EDILLON
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 1:222 N SUNSET AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2278
Mailing Address - Country:US
Mailing Address - Phone:626-338-1016
Mailing Address - Fax:626-960-5909
Practice Address - Street 1:222 N SUNSET AVE
Practice Address - Street 2:SUITE F
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2278
Practice Address - Country:US
Practice Address - Phone:626-338-1016
Practice Address - Fax:626-960-5909
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2009-06-10
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
CAA38045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A380450Medicaid
W13184Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER