Provider Demographics
NPI:1457309593
Name:GONCALVES, EDISON (MD)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:GONCALVES
Suffix:
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 1:3525 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5709
Mailing Address - Country:US
Mailing Address - Phone:205-971-2450
Mailing Address - Fax:
Practice Address - Street 1:3525 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-5709
Practice Address - Country:US
Practice Address - Phone:205-971-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17079207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529801810Medicaid
AL529801810Medicaid
F55745Medicare UPIN