Provider Demographics
NPI:1457464067
Name:DAMON, EDWIN STEVEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:STEVEN
Last Name:DAMON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 PALOMBA DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3844
Mailing Address - Country:US
Mailing Address - Phone:860-745-6248
Mailing Address - Fax:860-741-2482
Practice Address - Street 1:64 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3844
Practice Address - Country:US
Practice Address - Phone:860-745-6248
Practice Address - Fax:860-741-2482
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000035213E00000X
MA1422213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4006102Medicaid
CT1019700001OtherNSC
MA0313211Medicaid
MAY70554Medicare ID - Type Unspecified
MA0313211Medicaid
CT1019700001OtherNSC
CT480000194Medicare ID - Type Unspecified