Provider Demographics
NPI:1164624961
Name:EDGERTON, EDWIN OTIS III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:OTIS
Last Name:EDGERTON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:129 ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-2115
Mailing Address - Country:US
Mailing Address - Phone:318-396-6725
Mailing Address - Fax:318-396-6725
Practice Address - Street 1:129 ELMWOOD DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2115
Practice Address - Country:US
Practice Address - Phone:318-396-6725
Practice Address - Fax:318-396-6725
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA10357208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology