Provider Demographics
NPI:1922003706
Name:EDWARDS, RUSSELL PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PHILIP
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 1:3969 4TH AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3165
Mailing Address - Country:US
Mailing Address - Phone:858-566-0686
Mailing Address - Fax:
Practice Address - Street 1:3969 4TH AVE
Practice Address - Street 2:STE 301
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3165
Practice Address - Country:US
Practice Address - Phone:619-291-6191
Practice Address - Fax:619-291-0049
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57008207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18445Medicare ID - Type UnspecifiedMEDICARE GROUP ID
WG57008Medicare ID - Type UnspecifiedMEDICARE MEMBER ID
F21045Medicare UPIN