=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679572572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE DURNER EDSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2005
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DRIVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92134-5191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-7575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3456 MOON FIELD DR
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-729-2018
-----------------------------------------------------
Fax | 760-725-0117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | 036120197
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------