Provider Demographics
NPI:1235240177
Name:EDMONDS, DAVID S (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:EDMONDS
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 1:3109 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8830
Mailing Address - Country:US
Mailing Address - Phone:912-537-2436
Mailing Address - Fax:912-537-2659
Practice Address - Street 1:3109 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-2436
Practice Address - Fax:912-537-2659
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002008152W00000X
OH5027/T1904152W00000X
WV975-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFZBMedicare ID - Type UnspecifiedCMS CARRIER PROVIDER #
U79324Medicare UPIN
OH4013642Medicare PIN