Provider Demographics
NPI:1134113897
Name:TAXIN, EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:TAXIN
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 1:3012 E GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4231
Mailing Address - Country:US
Mailing Address - Phone:480-219-4476
Mailing Address - Fax:480-219-4898
Practice Address - Street 1:1492 SOUTH MILL AVENUE
Practice Address - Street 2:SUITE 312
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5676
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:480-927-1092
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1378207Q00000X
CA3791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ126524Medicare UPIN
AZZ120952Medicare PIN
AZZ126525Medicare UPIN
AZZ126048Medicare PIN