1023056108 NPI number — DR. JOHN RICHARD EDMISTON M .D.

Table of content: DR. JOHN RICHARD EDMISTON M .D. (NPI 1023056108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023056108 NPI number — DR. JOHN RICHARD EDMISTON M .D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMISTON
Provider First Name:
JOHN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M .D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023056108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27454 CASHFORD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESLEY CHAPEL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33544-8199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-995-0984
Provider Business Mailing Address Fax Number:
813-280-6193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27454 CASHFORD CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESLEY CHAPEL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33544-8199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-973-4747
Provider Business Practice Location Address Fax Number:
813-973-3799
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME40324 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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