Provider Demographics
NPI:1104922509
Name:AU, EDISON (PT)
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:AU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 STRATHMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1160
Mailing Address - Country:US
Mailing Address - Phone:301-946-1833
Mailing Address - Fax:
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:SUITE 1555
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6901
Practice Address - Country:US
Practice Address - Phone:301-951-8593
Practice Address - Fax:301-951-8598
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1452-0010OtherCAREFIRST
DC015212M60Medicare ID - Type Unspecified
DCQ27718Medicare UPIN