Provider Demographics
NPI:1124062005
Name:EDMONSON, ROBERT E (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:EDMONSON
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 1:221 W COLORADO BLVD
Mailing Address - Street 2:STE 625
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-946-5165
Mailing Address - Fax:214-946-4876
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:STE 625
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-946-5165
Practice Address - Fax:214-946-4876
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD0861207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060036498OtherRAILROAD MEDICARE
TX88K978OtherBLUE CROSS BLUE SHIELD
TX122747203Medicaid
C15419Medicare UPIN
TX122747203Medicaid