Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 12515R | LA |
N | 207Q00000X | Family Doctor | 84438 | GA |
N | 207QA0401X | Family Doctor - Addiction Medicine | 12515R | LA |
N | 207QA0401X | Family Doctor - Addiction Medicine | 84438 | GA |
NPI | 1568515419 |
---|---|
Provider Name | Dr. Antonio Dessell Edwards |
First Address | Plaquemine, LA 70764-4431 |
Second Address | Plaquemine, LA 70764-4431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 12/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1534358 | (05) | LA |
G64043 | (02) | LA |