Provider Demographics
NPI:1508033929
Name:EDGERSON-GEORGE, DEON
Entity Type:Individual
Prefix:
First Name:DEON
Middle Name:
Last Name:EDGERSON-GEORGE
Suffix:
Gender:F
Credentials:
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 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6576
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1630 MAIN ST
Practice Address - Street 2:SUITE 209
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2791
Practice Address - Country:US
Practice Address - Phone:410-643-4524
Practice Address - Fax:410-643-4523
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD74685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8573562OtherAETNA PPO
MD3156028OtherCIGNA
MD9144899OtherAETNA HMO
MDAB11-0002OtherCAREFIRST
MD056993300Medicaid
MD245337Y5ZMedicare PIN