Healthcare Provider Details

I. General information

NPI: 1922117894
Provider Name (Legal Business Name): KEITH C. EDWARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR. UCSD THORNTON HOSPITAL RADIOLOGY
LA JOLLA CA
92037-7756
US

IV. Provider business mailing address

200 W. ARBOR DR. UCSD MEDICAL CENTER, RADIOLOGY
SAN DIEGO CA
92103-8756
US

V. Phone/Fax

Practice location:
  • Phone: 619-471-9451
  • Fax:
Mailing address:
  • Phone: 619-471-9451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG33290
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG33290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: