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General NPI Number Information
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NPI Number | 1396942264
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Entity Type | Individual
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Provider Name | STEPHEN BLACKSTONE EDSTROM M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 06/06/2025
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Provider Practice Location Address
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Address Line | 1100 WILFORD HALL LOOP BLDG 4554
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City | JBSA LACKLAND
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State | TX
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Zip | 78236-5638
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Country | US
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Telephone | 210-292-6255
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Fax | 210-292-7934
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Provider Business Mailing Address
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Address Line | 4481 SUGAR MAPLE DR
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City | WRIGHT PATTERSON AFB
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State | OH
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Zip | 45433-5536
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Country | US
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Telephone | 937-257-0837
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01066091A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 35.151601
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License Number State | OH
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