Provider Demographics
NPI:1891180352
Name:DISTLER, EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:DISTLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 N PATTERSON ST STE 310
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2512
Mailing Address - Country:US
Mailing Address - Phone:229-433-8160
Mailing Address - Fax:220-244-2707
Practice Address - Street 1:2409 N PATTERSON ST STE 310
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2512
Practice Address - Country:US
Practice Address - Phone:229-433-8160
Practice Address - Fax:229-244-2707
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007087207R00000X
GA91531207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine