Healthcare Provider Details

I. General information

NPI: 1073817938
Provider Name (Legal Business Name): THOMAS E. EDWARDS, O.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10054 COOLEY RD
BROOKVILLE IN
47012-9511
US

IV. Provider business mailing address

10054 COOLEY RD
BROOKVILLE IN
47012-9511
US

V. Phone/Fax

Practice location:
  • Phone: 765-647-6883
  • Fax: 765-647-6883
Mailing address:
  • Phone: 765-647-6883
  • Fax: 765-647-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001538B
License Number StateIN

VIII. Authorized Official

Name: THOMAS EDWARDS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 765-647-6883