Basic Information
| Provider Information | |||||||||
| NPI: | 1720437908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MASON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759824196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 MILL ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759827878 | ||||||||
| FaxNumber: | 7759824196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DO2686 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | UO5016 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | DO2686 | NV | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1720437908 | 05 | FL | MEDICAID |