Provider Demographics
NPI:1053541706
Name:EDGERTON, DONALD G (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:G
Last Name:EDGERTON
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 1:2627 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-5240
Mailing Address - Country:US
Mailing Address - Phone:318-445-5485
Mailing Address - Fax:
Practice Address - Street 1:2627 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-5240
Practice Address - Country:US
Practice Address - Phone:318-445-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.009296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.009296OtherMEDICAL LICENSE