Provider Demographics
NPI:1073587945
Name:SAFARIAN, EDMOND K (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:K
Last Name:SAFARIAN
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:755 GRAND BLVD
Practice Address - Street 2:SUITE B105/228
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-1838
Practice Address - Country:US
Practice Address - Phone:850-797-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85762207P00000X
AL25073207P00000X
KY47821207P00000X
TNMD0000037004207P00000X
MO2014015861207P00000X
WAMD61088220207P00000X, 207Q00000X
AZ33147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ200036048OtherTRI CARE
AZAZ0778160OtherBLUE CROSS BLUE SHIELD
AZ991123Medicaid
FL5363245900Medicaid
AZG02957Medicare UPIN
AZ200036048OtherTRI CARE
FL5363245900Medicare Oscar/Certification
FL5363245900Medicare PIN
AZ991123Medicaid