Provider Demographics
NPI:1154316701
Name:EDWARDS, DALE (DO)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:EDWARDS
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:PO BOX 639619
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:859-655-8588
Practice Address - Street 1:2951 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1406
Practice Address - Country:US
Practice Address - Phone:513-672-3309
Practice Address - Fax:513-672-3323
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008029207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2451618Medicaid
OHED4116331Medicare ID - Type Unspecified