Healthcare Provider Details

I. General information

NPI: 1689093023
Provider Name (Legal Business Name): TRAVIS EDMISTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 IMPERIAL HWY
DOWNEY CA
90242-3456
US

IV. Provider business mailing address

4025 SW CONDOR AVE
PORTLAND OR
97239-4172
US

V. Phone/Fax

Practice location:
  • Phone: 562-385-7713
  • Fax:
Mailing address:
  • Phone: 541-740-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number165566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: