Provider Demographics
NPI:1699726976
Name:RUIZ DAVILA, EDMUNDO (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUNDO
Middle Name:
Last Name:RUIZ DAVILA
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 1:4087 PERALTA BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4849
Mailing Address - Country:US
Mailing Address - Phone:510-793-7555
Mailing Address - Fax:510-797-5372
Practice Address - Street 1:4087 PERALTA BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4849
Practice Address - Country:US
Practice Address - Phone:510-793-7555
Practice Address - Fax:510-797-5372
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A374100Medicare ID - Type Unspecified
CAD34069Medicare UPIN