Basic Information
| Provider Information | |||||||||
| NPI: | 1992812077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORDORICA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10050 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902677550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354056 | ||||||||
| FaxNumber: | 3103354098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 S LA BRUCHERIE RD | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922439676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603395620 | ||||||||
| FaxNumber: | 7603395621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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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 | 174400000X | G41911 | CA | N | Other Service Providers | Specialist | 2085R0001X | G41911 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00G419110 | 01 | CA | MEDI-CAL | OTHER | 1992812077 | 05 | CA | MEDICAID |