Provider Demographics
NPI:1477553956
Name:PERRY, EDWARD E (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:E
Last Name:PERRY
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 1:112 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2243
Mailing Address - Country:US
Mailing Address - Phone:618-244-0508
Mailing Address - Fax:618-244-0646
Practice Address - Street 1:112 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2243
Practice Address - Country:US
Practice Address - Phone:618-244-0508
Practice Address - Fax:618-244-0646
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL67035Medicare ID - Type Unspecified
ILU11853Medicare UPIN