Provider Demographics
NPI:1386706000
Name:EDWARDS, SAMUEL M (M D)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-736-7244
Mailing Address - Fax:386-736-8538
Practice Address - Street 1:750 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-736-7244
Practice Address - Fax:386-736-8538
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066309174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272821400Medicaid
FLF30037Medicare UPIN
FL272821400Medicaid