Provider Demographics
NPI:1104956382
Name:MADISON III, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:MADISON III
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 1:2765 SGT ALFRED DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-4013
Mailing Address - Country:US
Mailing Address - Phone:504-241-0861
Mailing Address - Fax:
Practice Address - Street 1:2765 SGT ALFRED DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-4013
Practice Address - Country:US
Practice Address - Phone:504-241-0861
Practice Address - Fax:985-288-5388
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1480631Medicaid
LA5A129Medicare PIN
G64117Medicare UPIN