Basic Information
| Provider Information | |||||||||
| NPI: | 1508050048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDENAS GOMEZ | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | IVON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | MP 80 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889123648 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 W UNDERWOOD ST | ||||||||
| Address2: | MP 80 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889123648 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N7236 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME113603 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME113603 | 01 | FL | MEDICAL LICENSE | OTHER | 005961600 | 05 | FL | MEDICAID |