Healthcare Provider Details

I. General information

NPI: 1013015585
Provider Name (Legal Business Name): STEPHEN PATRICK EDWARDS O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RAILROAD ST
WATER VALLEY MS
38965-3032
US

IV. Provider business mailing address

130 W VAN DORN AVE
HOLLY SPRINGS MS
38635-2902
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-2181
  • Fax: 662-473-2161
Mailing address:
  • Phone: 662-252-3323
  • Fax: 662-252-5858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number544
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: