Provider Demographics
NPI:1548369648
Name:FEDERMAN, EDWARD CHARLES (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
Last Name:FEDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91979-1009
Mailing Address - Country:US
Mailing Address - Phone:619-508-0908
Mailing Address - Fax:619-936-3242
Practice Address - Street 1:6699 ALVARADO RD STE 2309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5241
Practice Address - Country:US
Practice Address - Phone:619-286-8803
Practice Address - Fax:619-286-2344
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60283207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G602830Medicaid
CA00G602830Medicaid
BA510Medicare PIN
A57785Medicare UPIN