Provider Demographics
NPI:1427096080
Name:EMBORGO, EDWIN CONCERMAN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:CONCERMAN
Last Name:EMBORGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 630696
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-0696
Mailing Address - Country:US
Mailing Address - Phone:936-564-2691
Mailing Address - Fax:713-634-2636
Practice Address - Street 1:1023 N MOUND ST
Practice Address - Street 2:SUITE A
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4491
Practice Address - Country:US
Practice Address - Phone:936-564-2691
Practice Address - Fax:713-634-2636
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4705207Q00000X
TXM8458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203713701Medicaid
TXM8458OtherPHYSICIAN LICENSE
TXI52265Medicare UPIN
TX5N521Medicare PIN