Healthcare Provider Details

I. General information

NPI: 1962402347
Provider Name (Legal Business Name): WILLIAM CARLTON EDWARDS SR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 HIGHWAY 5
DOUGLASVILLE GA
30135-2378
US

IV. Provider business mailing address

3629 KIMBROUGH PT
DOUGLASVILLE GA
30135-1937
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-2020
  • Fax:
Mailing address:
  • Phone: 770-942-7675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1099-T
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: