Provider Demographics
NPI:1316037393
Name:EDWARDS, DOUGLAS J (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-1800
Mailing Address - Country:US
Mailing Address - Phone:507-377-3780
Mailing Address - Fax:507-377-7103
Practice Address - Street 1:1340 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-1800
Practice Address - Country:US
Practice Address - Phone:507-377-3780
Practice Address - Fax:507-377-7103
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2032111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65476Medicare UPIN