Provider Demographics
NPI:1326009291
Name:EDMUNDS, JUANA I (MD)
Entity Type:Individual
Prefix:DR
First Name:JUANA
Middle Name:I
Last Name:EDMUNDS
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 1:245 E 54TH ST
Mailing Address - Street 2:# 29 A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4707
Mailing Address - Country:US
Mailing Address - Phone:212-319-8069
Mailing Address - Fax:
Practice Address - Street 1:3811 BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4045
Practice Address - Country:US
Practice Address - Phone:718-726-5953
Practice Address - Fax:718-204-5308
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1330902084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00753984Medicaid
NY10D451Medicare ID - Type Unspecified
NY00753984Medicaid