Healthcare Provider Details

I. General information

NPI: 1659340719
Provider Name (Legal Business Name): ROBERT Z EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S MAIN ST
DEFOREST WI
53532-1480
US

IV. Provider business mailing address

815 S MAIN ST
DEFOREST WI
53532-1480
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-4605
  • Fax:
Mailing address:
  • Phone: 608-846-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44290
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: