Basic Information
| Provider Information | |||||||||
| NPI: | 1992708788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAUREL | ||||||||
| FirstName: | EDGARDO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 E CAMELBACK RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029970484 | ||||||||
| FaxNumber: | 6022243358 | ||||||||
| Practice Location | |||||||||
| Address1: | 2545 E THOMAS RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024193637 | ||||||||
| FaxNumber: | 6025951528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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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 | 207RN0300X | 21887 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 151605 | 05 | AZ | MEDICAID |