Provider Demographics
NPI:1699748020
Name:EDGINGTON, BRYAN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DAVID
Last Name:EDGINGTON
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:603-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:1331 NW LOVEJOY ST STE 750
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-535-2883
Practice Address - Fax:503-535-2887
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13975207W00000X
WAMD60801522207W00000X
ORMD159840207W00000X
DCMD036135207W00000X
MA223843207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500649006Medicaid
ID20013225OtherMEDICARE ID
WAG8975737OtherMEDICARE WA
WA2021463Medicaid
WAG8975734OtherMEDICARE WA
WAG8975735OtherMEDICARE WA
ORR199916OtherMEDICARE OR
ID20013225Medicaid
WAG8975733OtherMEDICARE WA
WAG8975736OtherMEDICARE WA