Provider Demographics
NPI:1881728905
Name:EDMISTON, HAROLD STUART (DO)
Entity type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:STUART
Last Name:EDMISTON
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 1:2320 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-9462
Mailing Address - Country:US
Mailing Address - Phone:937-895-4092
Mailing Address - Fax:937-855-6044
Practice Address - Street 1:2320 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:OH
Practice Address - Zip Code:45327-9462
Practice Address - Country:US
Practice Address - Phone:937-895-4092
Practice Address - Fax:937-855-6044
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004237A207QG0300X
OH34 003987207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN259370016Medicare PIN
000000820591OtherANTHEM
IN201165290Medicaid
OH0602253Medicaid