Provider Demographics
NPI:1992760250
Name:CORDIVIN, EDGAR R (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:R
Last Name:CORDIVIN
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 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516 EAST NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1192
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ168302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ182767Medicaid
Z116272Medicare PIN
73738Medicare ID - Type Unspecified
AZ182767Medicaid