Provider Demographics
NPI:1568515419
Name:EDWARDS, ANTONIO DESSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:DESSELL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:25073 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-4431
Mailing Address - Country:US
Mailing Address - Phone:225-687-1772
Mailing Address - Fax:225-687-1013
Practice Address - Street 1:25073 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-4431
Practice Address - Country:US
Practice Address - Phone:225-687-1772
Practice Address - Fax:225-687-1013
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84438207QA0401X, 405300000X, 207Q00000X
LA12515R405300000X, 207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1534358Medicaid
LAG64043Medicare UPIN
LA1534358Medicaid