Provider Demographics
NPI:1083670194
Name:EDWARDS, DAVID MITCHELL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MITCHELL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MATHEWS RDG
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-2852
Mailing Address - Country:US
Mailing Address - Phone:912-874-8664
Mailing Address - Fax:
Practice Address - Street 1:USS MARYLAND SSBN 738 BLUE
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34092-2129
Practice Address - Country:US
Practice Address - Phone:912-874-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman