Provider Demographics
NPI:1487692794
Name:EDWARDS, JOHN RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDALL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781090
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1090
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:8111 S EMERSON AVE # 105
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-5500
Practice Address - Fax:317-528-6316
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01072415A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31512OtherBCBS
370020210OtherRAILROAD MEDICARE
FL250625400Medicaid
E93092Medicare UPIN
370020210OtherRAILROAD MEDICARE