Provider Demographics
NPI:1588815054
Name:EDWARDS, MARC T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:T
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 HUNTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1018
Mailing Address - Country:US
Mailing Address - Phone:860-521-8484
Mailing Address - Fax:860-519-5674
Practice Address - Street 1:111 HUNTER DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1018
Practice Address - Country:US
Practice Address - Phone:860-521-8484
Practice Address - Fax:860-519-5674
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C15443Medicare UPIN