Provider Demographics
NPI:1124213459
Name:SHADZEKA, EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:SHADZEKA
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 1:4314 RUSTLING LEAVES TER
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3608
Mailing Address - Country:US
Mailing Address - Phone:301-806-2461
Mailing Address - Fax:
Practice Address - Street 1:4314 RUSTLING LEAVES TER
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3608
Practice Address - Country:US
Practice Address - Phone:301-806-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101998675Medicaid
PA116225PUDMedicare PIN
PA101998675Medicaid
PA116225ZC4DMedicare PIN