Provider Demographics
NPI:1336371723
Name:MICHAEL EDWARDS, D.P.M., P.A. PODIATRIST
Entity Type:Organization
Organization Name:MICHAEL EDWARDS, D.P.M., P.A. PODIATRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:432-934-4328
Mailing Address - Street 1:800 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4612
Mailing Address - Country:US
Mailing Address - Phone:432-332-1056
Mailing Address - Fax:866-982-9030
Practice Address - Street 1:800 E 7TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4612
Practice Address - Country:US
Practice Address - Phone:432-332-1056
Practice Address - Fax:866-982-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1879213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336371723Medicare UPIN
TX1952538878Medicare UPIN
TX6376380001Medicare NSC