Healthcare Provider Details

I. General information

NPI: 1871577288
Provider Name (Legal Business Name): GUY MITCHELL EDMONDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MULLET RUN
MILFORD DE
19963-5371
US

IV. Provider business mailing address

640 S. STATE STREET MAIL CODE 3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-424-0600
  • Fax: 302-422-6214
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC10004097
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: