Provider Demographics
NPI:1215379987
Name:EDGE, COLLEEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:D
Last Name:EDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8355 WALNUT HILL LN STE 105
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4242
Mailing Address - Country:US
Mailing Address - Phone:213-368-3659
Mailing Address - Fax:214-739-8923
Practice Address - Street 1:8355 WALNUT HILL LN STE 105
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4242
Practice Address - Country:US
Practice Address - Phone:213-368-3659
Practice Address - Fax:214-739-8923
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013259208000000X, 2080P0204X
TXR3502208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid