Provider Demographics
NPI:1164429890
Name:EDMONDSON, STEVEN RAY (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:RAY
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:RAY
Other - Last Name:EDMONDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:3025 N TARRANT PKWY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8620
Mailing Address - Country:US
Mailing Address - Phone:817-431-1500
Mailing Address - Fax:
Practice Address - Street 1:3025 N TARRANT PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8620
Practice Address - Country:US
Practice Address - Phone:817-431-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8830207VG0400X, 207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131769510Medicaid
TX83022YOtherBLUE CROSS BLUE SHIELD
TX131769508Medicaid
TX109380901Medicaid
TX131769502Medicaid
TX131769509Medicaid
TX0737147OtherUNITED HEALTHCARE
TX2357545OtherAETNA
TXC15418Medicare UPIN
TX8509J1Medicare ID - Type Unspecified
TX131769510Medicaid