Provider Demographics
NPI:1700955176
Name:EDWARDS, IVAN (DO)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 BANDERA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1445
Mailing Address - Country:US
Mailing Address - Phone:210-474-6788
Mailing Address - Fax:210-571-4105
Practice Address - Street 1:6502 BANDERA RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1445
Practice Address - Country:US
Practice Address - Phone:210-474-6788
Practice Address - Fax:210-571-4105
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6275208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation