Provider Demographics
NPI:1427115690
Name:EDGLEY, HARRISON B JR (MD)
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:B
Last Name:EDGLEY
Suffix:JR
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:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-0951
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:818-550-0909
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:888-453-6625
Practice Address - Fax:818-550-0909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50453207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A504530Medicaid
CAA50453OtherLICENSE
G15722Medicare UPIN
CA00A504531Medicare ID - Type UnspecifiedNHIC