Provider Demographics
NPI:1730152612
Name:EDGE, DUWAYNE PAUL (DO)
Entity type:Individual
Prefix:DR
First Name:DUWAYNE
Middle Name:PAUL
Last Name:EDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 AMARILLO ST
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-5710
Mailing Address - Country:US
Mailing Address - Phone:361-775-0961
Mailing Address - Fax:
Practice Address - Street 1:2605 AMARILLO ST
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:TX
Practice Address - Zip Code:78362-5710
Practice Address - Country:US
Practice Address - Phone:361-775-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101248603Medicaid
TX00415QMedicare ID - Type Unspecified
TXF87423Medicare UPIN
TX00415QMedicare PIN