Provider Demographics
NPI:1417365370
Name:EDWARDS, CAMILLE VANESSA (MB,BS)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:VANESSA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MB,BS
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:V
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE, 3RD FL
Practice Address - Street 2:MOAKLEY, HEMATOLOGY/ONCOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6428
Practice Address - Fax:617-638-5756
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA283337207R00000X, 207RH0000X, 207RX0202X
MAET90-064207R00000X, 207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110124511AMedicaid