Provider Demographics
NPI:1386225316
Name:ABDOU, EDMOND (MD)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:ABDOU
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 1:2525 BAYFRONT BLVD UNIT 255
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1669
Mailing Address - Country:US
Mailing Address - Phone:310-000-0000
Mailing Address - Fax:
Practice Address - Street 1:2525 BAYFRONT BLVD
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1609
Practice Address - Country:US
Practice Address - Phone:310-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine