Provider Demographics
NPI:1710119425
Name:MAXWELL, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MAXWELL
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 1:2250 HAYES ST
Mailing Address - Street 2:STE 302
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117
Mailing Address - Country:US
Mailing Address - Phone:415-750-5995
Mailing Address - Fax:415-666-3144
Practice Address - Street 1:2250 HAYES ST
Practice Address - Street 2:STE 302
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117
Practice Address - Country:US
Practice Address - Phone:415-750-5995
Practice Address - Fax:415-666-3144
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 1091412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA109141OtherMEDICAL LICENSE#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAFHC 70042FOtherSANTA CRUZ COUNTY MEDI-CAL PROVIDER #
CAFHC 70042FOtherSANTA CRUZ COUNTY MEDI-CAL PROVIDER #