Provider Demographics
NPI:1912985813
Name:EDMONDSON, EVERTON ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:EVERTON
Middle Name:ANTHONY
Last Name:EDMONDSON
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 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 1234
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-797-1180
Mailing Address - Fax:713-797-0641
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 1234
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-797-1180
Practice Address - Fax:713-797-0641
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9451208VP0014X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139241712Medicaid
TX139241716Medicaid
TX139241717Medicaid
TX8AJ445OtherBLUE CROSS
TX139241716Medicaid
TX139241717Medicaid
TXB80300Medicare UPIN
TX00J68EMedicare PIN