Provider Demographics
NPI:1104211283
Name:WASHINGTON, EDWARD THEODORE JR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:THEODORE
Last Name:WASHINGTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 WETHERBURN WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4611
Mailing Address - Country:US
Mailing Address - Phone:770-285-7010
Mailing Address - Fax:
Practice Address - Street 1:4045 WETHERBURN WAY STE 1
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4611
Practice Address - Country:US
Practice Address - Phone:770-285-7910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-05
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312393207W00000X
OH57027483207W00000X
KYTP126207W00000X
GA91739207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300039071Medicaid
KY7100669250Medicaid