Basic Information
Provider Information
NPI: 1003802935
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EDGEWORTH
FirstName: DEBORAH
MiddleName: J.
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2699
Address2:  
City: PENSACOLA
State: FL
PostalCode: 325132699
CountryCode: US
TelephoneNumber: 8504754500
FaxNumber: 8504754619
Practice Location
Address1: 120 N RICHARD JACKSON BLVD STE 130
Address2:  
City: PANAMA CITY BEACH
State: FL
PostalCode: 32407
CountryCode: US
TelephoneNumber: 8506086405
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/26/2005
LastUpdateDate: 08/21/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207V00000X14000MSN Allopathic & Osteopathic PhysiciansObstetrics & Gynecology 
207V00000XME75682FLY Allopathic & Osteopathic PhysiciansObstetrics & Gynecology 

ID Information
IDTypeStateIssuerDescription
25510630005FL MEDICAID


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