Basic Information
Provider Information | |||||||||
NPI: | 1174583579 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORELLANA | ||||||||
FirstName: | EDGAR | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ORELLANA | ||||||||
OtherFirstName: | EDGAR | ||||||||
OtherMiddleName: | G | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 5827 CORPORATE WAY | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334072000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5618449443 | ||||||||
FaxNumber: | 5614729692 | ||||||||
Practice Location | |||||||||
Address1: | 315 S W C OWENS AVE | ||||||||
Address2: |   | ||||||||
City: | CLEWISTON | ||||||||
State: | FL | ||||||||
PostalCode: | 334403637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8639837813 | ||||||||
FaxNumber: | 8639839604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2006 | ||||||||
LastUpdateDate: | 03/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME62808 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 373378500 | 05 | FL |   | MEDICAID | 18680 | 01 | FL | BCBS PROVIDER # | OTHER |