Provider Demographics
NPI:1093829657
Name:EDWARDS, BRAD REID (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:REID
Last Name:EDWARDS
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 1:3430 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7579
Mailing Address - Country:US
Mailing Address - Phone:208-523-3060
Mailing Address - Fax:208-523-0028
Practice Address - Street 1:3430 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7579
Practice Address - Country:US
Practice Address - Phone:208-523-3060
Practice Address - Fax:208-523-0028
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO316208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1285786046Medicaid
ID000010143893OtherBLUE SHIELD
ID806644500Medicaid
WY123957100Medicaid
MT0117436Medicaid
ID54380OtherBLUE CROSS
MT0117436Medicaid