Provider Demographics
NPI:1649394552
Name:EDWARDS, JOHN RAY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-8421
Mailing Address - Country:US
Mailing Address - Phone:802-658-2767
Mailing Address - Fax:802-862-4062
Practice Address - Street 1:118 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8421
Practice Address - Country:US
Practice Address - Phone:802-658-2767
Practice Address - Fax:802-862-4062
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2010-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00051572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005380Medicaid
VTVT 7996Medicare ID - Type UnspecifiedMEDICARE
VT0005380Medicaid