Provider Demographics
NPI:1972578565
Name:EDEEN, JOHN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:EDEEN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4499 MEDICAL DRIVE
Mailing Address - Street 2:SUITE 235
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3712
Mailing Address - Country:US
Mailing Address - Phone:210-692-1613
Mailing Address - Fax:210-616-0290
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:SUITE 235
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-692-1613
Practice Address - Fax:210-616-0290
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK3719207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX048514602OtherTPI
TX048514602Medicaid
TX048514602Medicaid
TX888056Medicare PIN