Provider Demographics
NPI:1689753824
Name:EDMONDSON, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:EDMONDSON
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:7800 SHOAL CREEK BLVD
Practice Address - Street 2:STE 130W
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1098
Practice Address - Country:US
Practice Address - Phone:713-874-0012
Practice Address - Fax:713-532-5756
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH77487Medicare UPIN