Provider Demographics
NPI:1023056108
Name:EDMISTON, JOHN RICHARD (M D)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:EDMISTON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27454 CASHFORD CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8199
Mailing Address - Country:US
Mailing Address - Phone:813-995-0984
Mailing Address - Fax:813-280-6193
Practice Address - Street 1:27454 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-8199
Practice Address - Country:US
Practice Address - Phone:813-973-4747
Practice Address - Fax:813-973-3799
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLD45242Medicare UPIN
FL23034Medicare ID - Type UnspecifiedMEDICARE NUMBER