Healthcare Provider Details

I. General information

NPI: 1295729648
Provider Name (Legal Business Name): EDGAR ARDILA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11705 SLATE AVE SUITE 200
RIVERSIDE CA
92505-5196
US

IV. Provider business mailing address

28030 BLACKBERRY WAY
YORBA LINDA CA
92887-5803
US

V. Phone/Fax

Practice location:
  • Phone: 951-351-1346
  • Fax: 951-359-3748
Mailing address:
  • Phone: 714-692-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA54539
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA54539
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA54539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: