Provider Demographics
NPI:1346382173
Name:EDMISTON, JOSEPH LEE (OD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:LEE
Last Name:EDMISTON
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 1:614 CUMBERLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-4374
Mailing Address - Country:US
Mailing Address - Phone:615-826-1611
Mailing Address - Fax:
Practice Address - Street 1:614 CUMBERLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-4374
Practice Address - Country:US
Practice Address - Phone:615-822-5381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN69274Medicaid
TN69274OtherBLUE CROSS BLUE SHEILD
TN3596139Medicare ID - Type Unspecified
TN69274Medicaid