Provider Demographics
NPI:1649243338
Name:EDMISTON, JOHN DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVIS
Last Name:EDMISTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVE
Other - Middle Name:
Other - Last Name:EDMISTON
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3480 CARLSBAD BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3225
Mailing Address - Country:US
Mailing Address - Phone:916-765-9261
Mailing Address - Fax:858-429-9969
Practice Address - Street 1:3480 CARLSBAD BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-3225
Practice Address - Country:US
Practice Address - Phone:916-765-9261
Practice Address - Fax:858-429-9969
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33644207W00000X, 2083P0901X
ORMD165316207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology