Provider Demographics
NPI:1902869597
Name:GRACIA-OLEA, EDGARDO
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:GRACIA-OLEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 4TH AVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4410
Mailing Address - Country:US
Mailing Address - Phone:619-425-7470
Mailing Address - Fax:619-425-7472
Practice Address - Street 1:480 4TH AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4410
Practice Address - Country:US
Practice Address - Phone:619-425-7470
Practice Address - Fax:619-425-7472
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33843174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA33843DMedicare ID - Type Unspecified