Healthcare Provider Details

I. General information

NPI: 1003177296
Provider Name (Legal Business Name): JEREMY DANIEL EDGERLY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 JEMISON LN
MOUNTAIN BROOK AL
35223-3003
US

IV. Provider business mailing address

921 JEMISON LN
MOUNTAIN BROOK AL
35223-3003
US

V. Phone/Fax

Practice location:
  • Phone: 205-341-9595
  • Fax: 205-341-9941
Mailing address:
  • Phone: 205-341-9595
  • Fax: 205-341-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-C78
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: