Provider Demographics
NPI:1588699904
Name:EDWARDS, GARY S (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9616 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5769
Mailing Address - Country:US
Mailing Address - Phone:479-242-8218
Mailing Address - Fax:479-242-8223
Practice Address - Street 1:9616 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5769
Practice Address - Country:US
Practice Address - Phone:479-242-8218
Practice Address - Fax:479-242-8223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-3105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080060546OtherRR MEDICARE
AR105874003Medicaid
AR51529Medicare ID - Type Unspecified
AR105874003Medicaid