Healthcare Provider Details

I. General information

NPI: 1952386179
Provider Name (Legal Business Name): THOMAS E EDWARDS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 04/20/2015
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:
Title or Position:
Credential:
Phone: