Provider Demographics
NPI:1851509723
Name:EDMUNDS, JOHN STEWART (MD, PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:STEWART
Last Name:EDMUNDS
Suffix:
Gender:M
Credentials:MD, PHD
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 63112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3112
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 NORTH ELM STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6304
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-016892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2085R0202XOtherTAXONOMY
VA1851509723OtherVIRGINIA MEDICAID
NC200701689OtherNC MEDICAL LICENSE
VA0101235502OtherVIRGINIA MEDICAL LICENSE
NCP00722341OtherMEDICARE RAILROAD
NC5908603Medicaid
NC2085R0202XOtherTAXONOMY