Provider Demographics
NPI:1588762504
Name:HA, EDWARD JIN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JIN
Last Name:HA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:1001 WILLOW CREEK RD STE 2200
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-445-6025
Practice Address - Fax:928-778-3026
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004018553207R00000X
IA37453207RC0000X
MO2008014944207RI0011X
AZ46688207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3085174Medicaid
WV3810018717Medicaid
KYP00875685OtherMEDICARE RAILROAD
AZ46688Other46688
KY7100137840Medicaid
KY7100137840Medicaid