Provider Demographics
NPI:1851327324
Name:EDMOND, CHARLES V JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:V
Last Name:EDMOND
Suffix:JR
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 1205
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0231
Mailing Address - Country:US
Mailing Address - Phone:253-770-9000
Mailing Address - Fax:253-770-9712
Practice Address - Street 1:104 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1145
Practice Address - Country:US
Practice Address - Phone:253-770-9000
Practice Address - Fax:253-770-9712
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD30364207Y00000X
WAMD00030364207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8145229Medicaid
WA8145229Medicaid
WAF49329Medicare UPIN