Healthcare Provider Details

I. General information

NPI: 1093705345
Provider Name (Legal Business Name): JULIA B EDWARDS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SOUTH MAIN ST.
DE FOREST WI
53532-1108
US

IV. Provider business mailing address

101 S. MAIN ST.
DE FOREST WI
53532-1108
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-5625
  • Fax: 608-846-8998
Mailing address:
  • Phone: 608-846-5625
  • Fax: 608-846-8998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2173
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: