Provider Demographics
NPI:1376661850
Name:EDLEFSEN, DAVID A (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:EDLEFSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:770 E MAIN ST
Mailing Address - Street 2:SUITE #133
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2284
Mailing Address - Country:US
Mailing Address - Phone:801-361-0143
Mailing Address - Fax:801-852-2841
Practice Address - Street 1:SEARS OPTICAL
Practice Address - Street 2:1200 TOWNE CENTRE BLVD.
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-852-2840
Practice Address - Fax:801-852-2841
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT109764-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist