Basic Information
Provider Information | |||||||||
NPI: | 1790964831 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDISON | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: | LUCILE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | WRAMC BLDG 2, ROOM 2J38 | ||||||||
Address2: | 6900 GEORGIA AVE. NW | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 203070001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2027826195 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | WRAMC BLDG 6, DEPARTMENT OF PSYCHIATRY | ||||||||
Address2: | 6900 GEORGIA AVE NW | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 203070001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2027826275 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2007 | ||||||||
LastUpdateDate: | 10/25/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | H42167 | MD | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 20A5219 (INACTIVE) | CA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | BE4940955 | 01 |   | DEA | OTHER |