Provider Demographics
NPI:1922295468
Name:JONATHAN D. EDWARDS, M.D.
Entity Type:Organization
Organization Name:JONATHAN D. EDWARDS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-675-5742
Mailing Address - Street 1:115 MEDICAL CIR
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-9124
Mailing Address - Country:US
Mailing Address - Phone:903-675-5742
Mailing Address - Fax:903-675-5677
Practice Address - Street 1:115 MEDICAL CIR
Practice Address - Street 2:SUITE 100B
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-9124
Practice Address - Country:US
Practice Address - Phone:903-675-5742
Practice Address - Fax:903-675-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX614228Medicare PIN