Provider Demographics
NPI:1093753329
Name:OVERTON, EDWARD ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ANTHONY
Last Name:OVERTON
Suffix:
Gender:M
Credentials:DO
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 480328
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5338
Mailing Address - Country:US
Mailing Address - Phone:215-669-9668
Mailing Address - Fax:704-864-3300
Practice Address - Street 1:2315 W ARBORS DR STE 115
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2639
Practice Address - Country:US
Practice Address - Phone:704-817-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-010979L2081P2900X
SC11462081P2900X
GA530112081P2900X
NC2004009342081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2335844000OtherIBC
SCNC1316Medicaid
PA3686882OtherAETNA
NC5908315Medicaid
6738998OtherCIGNA
PA088011GC6Medicare ID - Type Unspecified
SCNC1316Medicaid
PA3686882OtherAETNA
PAP00183284Medicare PIN