Healthcare Provider Details

I. General information

NPI: 1558528042
Provider Name (Legal Business Name): EDWARD J MADRID MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 S. DOBSON RD. SUITE B-218
CHANDLER AZ
85224-5671
US

IV. Provider business mailing address

655 S. DOBSON RD. SUITE B-218
CHANDLER AZ
85224-5671
US

V. Phone/Fax

Practice location:
  • Phone: 480-722-1180
  • Fax: 480-722-1187
Mailing address:
  • Phone: 480-722-1180
  • Fax: 480-722-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAZ16602
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16602
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier247454001
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 2
Identifier247454
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: