Provider Demographics
NPI:1003810367
Name:ATTAWAY, EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ATTAWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 AVENUE K SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4126
Mailing Address - Country:US
Mailing Address - Phone:863-294-3504
Mailing Address - Fax:863-294-8305
Practice Address - Street 1:407 AVENUE K SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4126
Practice Address - Country:US
Practice Address - Phone:863-294-3504
Practice Address - Fax:863-294-8305
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078605500Medicaid
FLT77514Medicare UPIN
FL078605500Medicaid