Provider Demographics
NPI:1720040504
Name:ALDERETE, EDWARD C (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:C
Last Name:ALDERETE
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 1:1400 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5906
Mailing Address - Country:US
Mailing Address - Phone:805-739-3358
Mailing Address - Fax:805-739-3060
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:805-739-3358
Practice Address - Fax:805-739-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-03822080N0001X
CAG30551208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G3055140Medicaid
CABT488OtherPALMETTO GBA: PART B PTAN
CAG30551OtherMEDICAL LICENSE
CABT488OtherPALMETTO GBA: PART B PTAN