Provider Demographics
NPI:1558791434
Name:EDWARDS, JOANNA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:ROSE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5003
Mailing Address - Country:US
Mailing Address - Phone:073-228-6454
Mailing Address - Fax:
Practice Address - Street 1:1565 SAXON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5876
Practice Address - Country:US
Practice Address - Phone:386-917-7395
Practice Address - Fax:386-532-7152
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN17612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014925500Medicaid