Basic Information
| Provider Information | |||||||||
| NPI: | 1932116472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDMONDS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870351520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 CENTRAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870351520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A-1270-04 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30827850 | 05 | NM | MEDICAID | 080165527 | 01 | NM | RAILROAD MEDICARE NUMBER | OTHER |