Healthcare Provider Details

I. General information

NPI: 1114232691
Provider Name (Legal Business Name): J DAVID EDWARDS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD SUITE 1265W
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD SUITE 1265W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-8566
  • Fax: 310-453-9531
Mailing address:
  • Phone: 310-828-8566
  • Fax: 310-453-9531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA26085
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN DAVID EDWARDS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-828-8566