Provider Demographics
NPI:1679540702
Name:EDMUNDS, MARK JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:EDMUNDS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1610 S MAIN ST
Mailing Address - Street 2:STE. 9
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1974
Mailing Address - Country:US
Mailing Address - Phone:270-885-1203
Mailing Address - Fax:270-885-1561
Practice Address - Street 1:1610 S MAIN ST
Practice Address - Street 2:STE. 9
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1974
Practice Address - Country:US
Practice Address - Phone:270-885-1203
Practice Address - Fax:270-885-1561
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00294213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8000490Medicaid
KYP00713506OtherRAILROAD MEDICARE
KY00786001Medicare PIN
KYU98518Medicare UPIN