Healthcare Provider Details

I. General information

NPI: 1841638004
Provider Name (Legal Business Name): GEORGE STEPHEN EDWARDSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-4784
  • Fax:
Mailing address:
  • Phone: 937-522-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0470289002
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: