=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689817843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDGARD CHAVEZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2009
-----------------------------------------------------
Last Update Date | 04/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 N CENTRAL AVE SUITE 100
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-388-9066
-----------------------------------------------------
Fax | 772-388-9067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3897 PEACOCK DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32904-9516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-745-5954
-----------------------------------------------------
Fax | 772-388-9067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME104256
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------