Provider Demographics
NPI:1740258300
Name:EDWARDS, JOHNATHAN J (MD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:J
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 1:5300 S ATLANTIC AVE APT 19602
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-7522
Mailing Address - Country:US
Mailing Address - Phone:702-222-3238
Mailing Address - Fax:702-221-2231
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-3072
Practice Address - Fax:386-231-5962
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10500207L00000X
FLME119864207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504572Medicaid
NV39740Medicare ID - Type Unspecified