Healthcare Provider Details

I. General information

NPI: 1093097735
Provider Name (Legal Business Name): EDSEL IWAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 S BRONCO ST
LAS VEGAS NV
89146-5207
US

IV. Provider business mailing address

2855 S BRONCO ST
LAS VEGAS NV
89146-5207
US

V. Phone/Fax

Practice location:
  • Phone: 888-499-9273
  • Fax: 702-926-9658
Mailing address:
  • Phone: 412-519-5197
  • Fax: 702-685-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15335
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.133914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: