Provider Demographics
NPI:1114969201
Name:EDGE, JOHNATHON CURTIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:CURTIS
Last Name:EDGE
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 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG E SUITE 205
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-852-1645
Mailing Address - Fax:270-852-1646
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG E SUITE 205
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-852-1645
Practice Address - Fax:270-852-1646
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39536207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000489532OtherANTHEM
KY64127699Medicaid
KY000000489532OtherANTHEM
KYP00371965Medicare PIN
KY64127699Medicaid
KYI34136Medicare UPIN
KY00113001Medicare PIN
KY1307425Medicare PIN