Basic Information
| Provider Information | |||||||||
| NPI: | 1730279035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAVALERCHIK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR, 111-E | ||||||||
| Address2: | VA SD LA JOLLA MEDICAL CTR | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423356 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR, 111-E | ||||||||
| Address2: | VA SD LA JOLLA MEDICAL CTR | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423356 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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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 | 207R00000X | A87968 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | A87968 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | A87968 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1730279035 | 05 | CA | MEDICAID |