Basic Information
| Provider Information | |||||||||
| NPI: | 1033157235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9930 TALBERT AVE. | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149646229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9930 TALBERT AVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149646229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A6550 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00XA65500 | 05 | CA | MEDICAID |