Healthcare Provider Details

I. General information

NPI: 1548269285
Provider Name (Legal Business Name): JEREMY VAUGHAN EDWARDS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 05/02/2020
Certification Date: 05/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 NORTH PALMER ROAD DEPARTMENT OF PEDIATRICS
BETHESDA MD
20889-5001
US

IV. Provider business mailing address

21320 RIDGECROFT DR
BROOKEVILLE MD
20833-1818
US

V. Phone/Fax

Practice location:
  • Phone: 301-400-3327
  • Fax:
Mailing address:
  • Phone: 808-233-9121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDOS951
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberDOS951
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberDOS951
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: