Healthcare Provider Details

I. General information

NPI: 1134105919
Provider Name (Legal Business Name): EDWARD JOHN PRIMKA III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 DOWELL SPRINGS BLVD STE 210
KNOXVILLE TN
37909-2448
US

IV. Provider business mailing address

1450 DOWELL SPRINGS BLVD STE 210
KNOXVILLE TN
37909-2448
US

V. Phone/Fax

Practice location:
  • Phone: 865-524-2547
  • Fax: 865-205-5601
Mailing address:
  • Phone: 865-524-2547
  • Fax: 865-205-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD0000035486
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD0000035486
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD0000035486
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: