Healthcare Provider Details

I. General information

NPI: 1992760250
Provider Name (Legal Business Name): EDGAR R CORDIVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1192
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16830
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: