Healthcare Provider Details

I. General information

NPI: 1023216678
Provider Name (Legal Business Name): EDGAR ALEXANDER CHAVEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 E WASHINGTON BLVD STE A
LOS ANGELES CA
90021-3020
US

IV. Provider business mailing address

2801 S SAN PEDRO ST
LOS ANGELES CA
90011-2023
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-3100
  • Fax: 213-745-3626
Mailing address:
  • Phone: 323-233-3100
  • Fax: 323-233-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA92965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: