Individual
EDISON AU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
5454 WISCONSIN AVE, SUITE 1555, CHEVY CHASE, MD 20815-6901
(301) 951-8593
(301) 951-8598
Mailing address
5353 STRATHMORE AVE, KENSINGTON, MD 20895-1160
(301) 946-1833
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
21330
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1452-0010
CAREFIRST
DC
Enumeration date
09/15/2006
Last updated
07/08/2007
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