Provider Demographics
NPI:1942389754
Name:FESTUS, EDWARD O (MD,RPA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:O
Last Name:FESTUS
Suffix:
Gender:M
Credentials:MD,RPA
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 995
Mailing Address - Street 2:WILLIAMSBRIDGE STN
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-0726
Mailing Address - Country:US
Mailing Address - Phone:914-672-6858
Mailing Address - Fax:
Practice Address - Street 1:8209 ROOSEVELT AVE FL 2
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7034
Practice Address - Country:US
Practice Address - Phone:718-507-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004555-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical