Provider Demographics
NPI:1346220688
Name:GRESHAM, EDWARD A (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-0340
Mailing Address - Country:US
Mailing Address - Phone:870-364-9111
Mailing Address - Fax:870-364-5581
Practice Address - Street 1:909 UNITY RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-9444
Practice Address - Country:US
Practice Address - Phone:870-364-9111
Practice Address - Fax:870-364-5581
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARG5569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104845001Medicaid
AR15181OtherQUALCHOICE
AR15181OtherQUALCHOICE
AR104845001Medicaid