Provider Demographics
NPI:1184019325
Name:PREVATT, EDWARD G (MD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:G
Last Name:PREVATT
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 1:648 NEWTON PL NW
Mailing Address - Street 2:APT 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1737
Mailing Address - Country:US
Mailing Address - Phone:240-533-1805
Mailing Address - Fax:
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-2586
Practice Address - Fax:360-428-6470
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61223363208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery