Provider Demographics
NPI:1689093023
Name:EDMISTON, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:EDMISTON
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 1:4025 SW CONDOR AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4172
Mailing Address - Country:US
Mailing Address - Phone:541-740-8978
Mailing Address - Fax:
Practice Address - Street 1:7601 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3456
Practice Address - Country:US
Practice Address - Phone:562-385-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1655662081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program