Provider Demographics
NPI:1710952452
Name:EDWARDS, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:EDWARDS
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:P.O. BOX 488
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0488
Mailing Address - Country:US
Mailing Address - Phone:336-623-9711
Mailing Address - Fax:336-627-0778
Practice Address - Street 1:520 SOUTH VAN BUREN ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5019
Practice Address - Country:US
Practice Address - Phone:336-627-7500
Practice Address - Fax:336-627-7384
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-029533207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010242151Medicaid
VA6408826Medicaid
200001179Medicare PIN
VAB08335Medicare UPIN