Provider Demographics
NPI:1487767653
Name:MALBAS, EDGAR NEPOMUCENO (PT)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:NEPOMUCENO
Last Name:MALBAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8721 BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1097
Mailing Address - Country:US
Mailing Address - Phone:949-836-2018
Mailing Address - Fax:
Practice Address - Street 1:8721 BALD EAGLE DR
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-1097
Practice Address - Country:US
Practice Address - Phone:949-836-2018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT240152251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT240150OtherBLUE SHIELD
CAWPT24015AMedicare ID - Type Unspecified