Healthcare Provider Details

I. General information

NPI: 1992468623
Provider Name (Legal Business Name): EDGAR LEONARDO FARIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 E FLORENCE AVE
LOS ANGELES CA
90001-1937
US

IV. Provider business mailing address

1414 E FLORENCE AVE
LOS ANGELES CA
90001-1937
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-1383
  • Fax:
Mailing address:
  • Phone: 323-588-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA60614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: