Provider Demographics
NPI:1225334683
Name:CORYDON G EDGECOMB OD INC
Entity Type:Organization
Organization Name:CORYDON G EDGECOMB OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CORYDON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGECOMB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-622-7660
Mailing Address - Street 1:1287 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5820
Mailing Address - Country:US
Mailing Address - Phone:530-622-7660
Mailing Address - Fax:530-622-3753
Practice Address - Street 1:1287 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5820
Practice Address - Country:US
Practice Address - Phone:530-622-7660
Practice Address - Fax:530-622-3753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 4245 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEM015AMedicare PIN
CA1225334683Medicare UPIN