Provider Demographics
NPI:1053420190
Name:EDMISTON, WILLIAM JOHN JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:EDMISTON
Suffix:JR
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 1:170 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:704-360-4378
Mailing Address - Fax:704-696-8150
Practice Address - Street 1:170 MEDICAL PARK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:704-360-4378
Practice Address - Fax:704-696-8150
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000410208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891269NMedicaid
NCBE5025487OtherDEA
NCNC1272A212Medicare PIN