Provider Demographics
NPI:1407811128
Name:EDMISTON, WALTER ALLAN JR (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:ALLAN
Last Name:EDMISTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E CALIFORNIA BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3944
Mailing Address - Country:US
Mailing Address - Phone:626-793-1227
Mailing Address - Fax:626-793-3794
Practice Address - Street 1:55 E CALIFORNIA BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3944
Practice Address - Country:US
Practice Address - Phone:626-793-1227
Practice Address - Fax:626-793-3794
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23064207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01575801OtherMCR RR
CAG23064OtherBLUE SHIELD
CAG23064OtherST LIC NUMBER
CAP01575801OtherMCR RR
CAG23064OtherST LIC NUMBER