Provider Demographics
NPI:1336212679
Name:GIFFIN, EDWARD LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEROY
Last Name:GIFFIN
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 1:1 MAXWELL GLN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1262
Mailing Address - Country:US
Mailing Address - Phone:210-670-9030
Mailing Address - Fax:210-675-4072
Practice Address - Street 1:1 MAXWELL GLN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1262
Practice Address - Country:US
Practice Address - Phone:210-670-9030
Practice Address - Fax:210-675-4072
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3557207Y00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120583303Medicaid
TX120583303Medicaid
TX80W750Medicare ID - Type Unspecified