Provider Demographics
NPI:1861925471
Name:EGESDAL, CHARLES SANFORD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SANFORD
Last Name:EGESDAL
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 1:3501 S HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6919
Mailing Address - Country:US
Mailing Address - Phone:714-929-2300
Mailing Address - Fax:
Practice Address - Street 1:3501 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6919
Practice Address - Country:US
Practice Address - Phone:714-929-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157470208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics