Provider Demographics
NPI:1760235733
Name:EDWARDS, LAVON (MD)
Entity Type:Individual
Prefix:
First Name:LAVON
Middle Name:
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 1:6559 W FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-2522
Mailing Address - Country:US
Mailing Address - Phone:254-462-9406
Mailing Address - Fax:
Practice Address - Street 1:6559 W FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-2522
Practice Address - Country:US
Practice Address - Phone:254-462-9406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty