Healthcare Provider Details

I. General information

NPI: 1871882712
Provider Name (Legal Business Name): EDGAR S. MACIAS, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7115 N CHESTNUT AVE STE 101
FRESNO CA
93720-0361
US

IV. Provider business mailing address

7115 N CHESTNUT AVE STE 101
FRESNO CA
93720-0361
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-2397
  • Fax: 559-472-3382
Mailing address:
  • Phone: 559-431-2397
  • Fax: 559-472-3382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA112259
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: VANESSA CANEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 559-431-2397