Healthcare Provider Details

I. General information

NPI: 1679572572
Provider Name (Legal Business Name): THEODORE DURNER EDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DRIVE
SAN DIEGO CA
92134-5191
US

IV. Provider business mailing address

3456 MOON FIELD DR
CARLSBAD CA
92008-5542
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7575
  • Fax:
Mailing address:
  • Phone: 760-729-2018
  • Fax: 760-725-0117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036120197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: