Provider Demographics
NPI:1598104846
Name:LEO K. EDWARDS JR
Entity Type:Organization
Organization Name:LEO K. EDWARDS JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:K
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:210-225-5047
Mailing Address - Street 1:2011 E HOUSTON ST
Mailing Address - Street 2:SUITE #104 C
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78202-2916
Mailing Address - Country:US
Mailing Address - Phone:210-225-5047
Mailing Address - Fax:210-225-7951
Practice Address - Street 1:2011 E HOUSTON ST
Practice Address - Street 2:SUITE #104 C
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78202-2916
Practice Address - Country:US
Practice Address - Phone:210-225-5047
Practice Address - Fax:210-225-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035375701Medicaid
TX1750313442OtherNPI (INDIVIDUAL)
TX00PP09Medicare PIN
TX035375701Medicaid