Provider Demographics
NPI:1689806093
Name:ETHEREDGE, JAMES L (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:ETHEREDGE
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 1:21 S CASEREA CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1065
Mailing Address - Country:US
Mailing Address - Phone:772-231-4657
Mailing Address - Fax:
Practice Address - Street 1:21 S CASEREA CT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-1065
Practice Address - Country:US
Practice Address - Phone:772-231-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.04187R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty