Provider Demographics
NPI:1114206034
Name:EDMUNDS, DAVID O
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:O
Last Name:EDMUNDS
Suffix:
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 1:7321 BALMER ST BLDG 570
Mailing Address - Street 2:
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 N 300 W STE 204
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3374
Practice Address - Country:US
Practice Address - Phone:801-357-7373
Practice Address - Fax:801-357-7217
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9037744-9934152W00000X
UT9037744-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist