Provider Demographics
NPI:1649299199
Name:EDWARDS, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 SHAW AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4002
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:215 N. FRESNO ST.
Practice Address - Street 2:370
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701
Practice Address - Country:US
Practice Address - Phone:559-459-2327
Practice Address - Fax:559-459-1539
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG38967208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G389670Medicaid
CAA47652Medicare UPIN