Provider Demographics
NPI:1992468623
Name:FARIAS, EDGAR LEONARDO
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:LEONARDO
Last Name:FARIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 E GAGE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-3548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1937
Practice Address - Country:US
Practice Address - Phone:323-588-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program