Provider Demographics
NPI:1962412304
Name:MALDONADO, ERNIE (MD)
Entity type:Individual
Prefix:
First Name:ERNIE
Middle Name:
Last Name:MALDONADO
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 1:223 N 1ST AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-7089
Mailing Address - Country:US
Mailing Address - Phone:626-821-1411
Mailing Address - Fax:
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:PEDIATRICS DEPARTMENT
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-3082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A525120OtherBLUE SHIELD
CA00A525120OtherBLUE SHIELD