Provider Demographics
NPI:1467899609
Name:EDAKKUNNATHU, ALWIN (OD)
Entity Type:Individual
Prefix:
First Name:ALWIN
Middle Name:
Last Name:EDAKKUNNATHU
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 1:5150 N PORT WASHINGTON RD STE 251
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5477
Mailing Address - Country:US
Mailing Address - Phone:414-332-0606
Mailing Address - Fax:
Practice Address - Street 1:5150 N PORT WASHINGTON RD STE 251
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5477
Practice Address - Country:US
Practice Address - Phone:414-332-0606
Practice Address - Fax:414-967-3604
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3300-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist