Provider Demographics
NPI:1265419113
Name:MISSE', EDOUARD (MD)
Entity type:Individual
Prefix:
First Name:EDOUARD
Middle Name:
Last Name:MISSE'
Suffix:
Gender:M
Credentials:MD
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 1385
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-1385
Mailing Address - Country:US
Mailing Address - Phone:252-209-5404
Mailing Address - Fax:252-209-3490
Practice Address - Street 1:700 ACADEMY ST S
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3264
Practice Address - Country:US
Practice Address - Phone:252-209-5404
Practice Address - Fax:252-209-3490
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100577208600000X
NCMD039134L174400000X
PAPA200100577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC129V4OtherBLUECROSS BLUESHIELD
NC89129V4Medicaid
2288312AMedicare ID - Type Unspecified
NC129V4OtherBLUECROSS BLUESHIELD