Provider Demographics
NPI:1376686261
Name:EDWARDS, JOHN T (ST)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:T
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14506 W GRANITE VALLEY DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-6010
Mailing Address - Country:US
Mailing Address - Phone:623-584-5626
Mailing Address - Fax:623-584-8998
Practice Address - Street 1:14506 W GRANITE VALLEY DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-6010
Practice Address - Country:US
Practice Address - Phone:623-584-5626
Practice Address - Fax:623-584-8998
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTR1913247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist