Provider Demographics
NPI:1528134319
Name:EDMISTON, RICHARD ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
Last Name:EDMISTON
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 1:4324 DANT BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-7017
Mailing Address - Country:US
Mailing Address - Phone:775-827-6292
Mailing Address - Fax:775-827-1032
Practice Address - Street 1:2375 E PRATER WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9641
Practice Address - Country:US
Practice Address - Phone:775-356-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV44102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016811Medicaid
NV880183937OtherEIN
NVWQBBH01Medicare ID - Type UnspecifiedMEDICARE
NV002016811Medicaid