Provider Demographics
NPI:1013015585
Name:EDWARDS, STEPHEN PATRICK (O D)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PATRICK
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W VAN DORN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-2902
Mailing Address - Country:US
Mailing Address - Phone:662-252-3323
Mailing Address - Fax:662-252-5858
Practice Address - Street 1:302 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3032
Practice Address - Country:US
Practice Address - Phone:662-473-2181
Practice Address - Fax:662-473-2161
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880206Medicaid
MS00880206Medicaid
MST93632Medicare UPIN