Provider Demographics
NPI:1669471736
Name:EDWARDS, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:11541 E WINCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2040
Mailing Address - Country:US
Mailing Address - Phone:833-220-2685
Mailing Address - Fax:317-947-0839
Practice Address - Street 1:8240 NAAB ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-338-7450
Practice Address - Fax:317-338-7457
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033757A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100129200Medicaid
IN1009224OtherTRICARE
E14001Medicare UPIN
IN100129200Medicaid