Provider Demographics
NPI:1932116472
Name:EDMONDS, JEREMY TODD (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:EDMONDS
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:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1520
Mailing Address - Country:US
Mailing Address - Phone:505-832-4434
Mailing Address - Fax:505-832-5024
Practice Address - Street 1:1108 CENTRAL AVE SW
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-1520
Practice Address - Country:US
Practice Address - Phone:505-832-4434
Practice Address - Fax:505-832-5024
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1270-04207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30827850Medicaid
NM080165527OtherRAILROAD MEDICARE NUMBER
NM080165527OtherRAILROAD MEDICARE NUMBER
NM30827850Medicaid