Provider Demographics
NPI:1063623882
Name:JOHN B. EDWARDS, MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN B. EDWARDS, MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-1800
Mailing Address - Street 1:5680 N FRESNO ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8331
Mailing Address - Country:US
Mailing Address - Phone:559-435-1800
Mailing Address - Fax:559-432-6435
Practice Address - Street 1:5680 N FRESNO ST
Practice Address - Street 2:SUITE 107
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8331
Practice Address - Country:US
Practice Address - Phone:559-435-1800
Practice Address - Fax:559-432-6435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38967208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G389670Medicaid
CA00G389670Medicaid
CA00G389670Medicare PIN