Provider Demographics
NPI:1134116643
Name:EDISON, JOHN M (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:EDISON
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 1:3003 LOMA VISTA RD
Mailing Address - Street 2:STE. A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2935
Mailing Address - Country:US
Mailing Address - Phone:805-648-3081
Mailing Address - Fax:805-648-2659
Practice Address - Street 1:3003 LOMA VISTA RD
Practice Address - Street 2:STE. A
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2935
Practice Address - Country:US
Practice Address - Phone:805-648-3081
Practice Address - Fax:805-648-2659
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27589207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C27589OtherALL OTHER INSURANCES
00C275890OtherBLUE SHIELD OF CALIFORNIA
CA00C275890Medicaid
C27589OtherALL OTHER INSURANCES
WC27589BMedicare ID - Type Unspecified