Provider Demographics
NPI:1124382742
Name:EDEEN, RICHARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:EDEEN
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 1:2 SAINT MARKS PL STE 110
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1255
Mailing Address - Country:US
Mailing Address - Phone:979-242-2387
Mailing Address - Fax:979-242-2206
Practice Address - Street 1:2 SAINT MARKS PL STE 110
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1255
Practice Address - Country:US
Practice Address - Phone:979-242-2387
Practice Address - Fax:979-242-2206
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35130913207X00000X
390200000X
TXR7000207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program