Provider Demographics
NPI:1720097298
Name:EDWARDS, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:EDWARDS
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 1:212 W CAYUGA DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3204
Mailing Address - Country:US
Mailing Address - Phone:903-675-5742
Mailing Address - Fax:903-904-5234
Practice Address - Street 1:212 W CAYUGA DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3204
Practice Address - Country:US
Practice Address - Phone:903-675-5742
Practice Address - Fax:903-904-5234
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120530402Medicaid
TX120530402Medicaid
TXF47488Medicare UPIN