Healthcare Provider Details

I. General information

NPI: 1033601083
Provider Name (Legal Business Name): EDWARD W. VERDE, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVENUE
MODESTO CA
95350-4418
US

IV. Provider business mailing address

817 COFFEE ROAD C3
MODESTO CA
95355-4241
US

V. Phone/Fax

Practice location:
  • Phone: 209-529-9603
  • Fax: 209-529-6610
Mailing address:
  • Phone: 209-529-9603
  • Fax: 209-529-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA68621
License Number StateCA

VIII. Authorized Official

Name: EDWARD WAYNE VERDE
Title or Position: PRESIDENT
Credential: MD
Phone: 909-708-6912