Healthcare Provider Details

I. General information

NPI: 1790986735
Provider Name (Legal Business Name): EDWARD ALAN HIRSCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 TRAIL VIEW PL
NIPOMO CA
93444-6663
US

IV. Provider business mailing address

1200 TRAIL VIEW PL
NIPOMO CA
93444-6663
US

V. Phone/Fax

Practice location:
  • Phone: 309-657-9919
  • Fax:
Mailing address:
  • Phone: 309-657-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG142753
License Number StateCA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: