Healthcare Provider Details

I. General information

NPI: 1083670194
Provider Name (Legal Business Name): DAVID MITCHELL EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS MARYLAND SSBN 738 BLUE
FPO AA
34092-2129
US

IV. Provider business mailing address

304 MATHEWS RDG
SAINT MARYS GA
31558-2852
US

V. Phone/Fax

Practice location:
  • Phone: 912-874-8664
  • Fax:
Mailing address:
  • Phone: 912-874-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number1710I1002X
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: