Provider Demographics
NPI:1144204629
Name:EDMONDS, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:EDMONDS
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 1:5050 SKYLINE VILLAGE LOOP S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9490
Mailing Address - Country:US
Mailing Address - Phone:503-391-1110
Mailing Address - Fax:503-370-4237
Practice Address - Street 1:5050 SKYLINE VILLAGE LOOP S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9490
Practice Address - Country:US
Practice Address - Phone:503-391-1110
Practice Address - Fax:503-370-4237
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR152413Medicaid
OR152413Medicaid
C91306Medicare UPIN