Provider Demographics
NPI:1235450404
Name:DUWAYNE P. EDGE, P.A.
Entity Type:Organization
Organization Name:DUWAYNE P. EDGE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUWAYNE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-775-0961
Mailing Address - Street 1:P.O. BOX 1507
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-1507
Mailing Address - Country:US
Mailing Address - Phone:361-775-0961
Mailing Address - Fax:361-775-0960
Practice Address - Street 1:2605 AMARILLO
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:TX
Practice Address - Zip Code:78362-5710
Practice Address - Country:US
Practice Address - Phone:361-775-0961
Practice Address - Fax:361-775-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101248603Medicaid
TX101248603Medicaid