Provider Demographics
NPI:1366827644
Name:EDWARDS, NATHANIEL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:DAVID
Last Name:EDWARDS
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 1:1619 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1725
Mailing Address - Country:US
Mailing Address - Phone:580-255-1172
Mailing Address - Fax:580-255-1234
Practice Address - Street 1:1619 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1725
Practice Address - Country:US
Practice Address - Phone:580-255-1172
Practice Address - Fax:580-255-1234
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist