Provider Demographics
NPI:1649257452
Name:EDMOND, MICHAEL T (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:EDMOND
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 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-231-5201
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6071207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130017527Medicaid
TX130204408Medicaid
TX130204409Medicaid
TXEZ64Medicare PIN
TX8K9301Medicare PIN
TX8K9297Medicare PIN
TX130204408Medicaid