Provider Demographics
NPI:1942259262
Name:EDOZIEN, ANTHONY O (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:O
Last Name:EDOZIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-4613
Mailing Address - Fax:410-706-4619
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-706-4613
Practice Address - Fax:410-706-4619
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD62230207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4059522-00OtherBLUE CROSS/BLUE SHIELD
MD405952200Medicaid
MDS033J788Medicare PIN
MDP01291432Medicare PIN
MDG26360Medicare UPIN