Healthcare Provider Details

I. General information

NPI: 1134116643
Provider Name (Legal Business Name): JOHN M EDISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 LOMA VISTA RD STE. A
VENTURA CA
93003-2935
US

IV. Provider business mailing address

3003 LOMA VISTA RD STE. A
VENTURA CA
93003-2935
US

V. Phone/Fax

Practice location:
  • Phone: 805-648-3081
  • Fax: 805-648-2659
Mailing address:
  • Phone: 805-648-3081
  • Fax: 805-648-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberC27589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: