Provider Demographics
NPI:1255622015
Name:EDGECOMBE, JAVON MIGUEL (MD)
Entity type:Individual
Prefix:
First Name:JAVON
Middle Name:MIGUEL
Last Name:EDGECOMBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAVON
Other - Middle Name:M
Other - Last Name:EDGECOMBE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-985-9427
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01012689562084N0400X
NC2016-011882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program