Provider Demographics
NPI:1952961294
Name:EDGERSON, DAVID E
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:EDGERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E FM 1382 # 3-166
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-6047
Mailing Address - Country:US
Mailing Address - Phone:469-377-0808
Mailing Address - Fax:
Practice Address - Street 1:445 E FM 1382 # 3-166
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-6047
Practice Address - Country:US
Practice Address - Phone:469-377-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor