Provider Demographics
NPI:1265534234
Name:EDWARDS, CHARLES FESSENDEN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES FESSENDEN
Middle Name:
Last Name:EDWARDS
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:FILE #54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:858-784-5767
Mailing Address - Fax:858-784-5933
Practice Address - Street 1:15025 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3409
Practice Address - Country:US
Practice Address - Phone:858-487-1800
Practice Address - Fax:858-784-5933
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30356207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G303560Medicaid
CAA44391Medicare UPIN
CAWG30356FMedicare PIN