Provider Demographics
NPI:1134122104
Name:EDWARDS, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:EDWARDS
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 1:1000 ASYLUM AVE
Mailing Address - Street 2:STE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1719
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:94 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1217
Practice Address - Country:US
Practice Address - Phone:860-714-4680
Practice Address - Fax:860-714-8047
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020052207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001200526Medicaid
CT001200526Medicaid
CTE61144Medicare UPIN