Provider Demographics
NPI: | 1508903253 |
---|---|
Name: | EDWARDS, ROBERT A (OD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROBERT |
Middle Name: | A |
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: | 506 BELTRAMI AVE NW |
Mailing Address - Street 2: | |
Mailing Address - City: | BEMIDJI |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56601-3010 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 506 BELTRAMI AVE NW |
Practice Address - Street 2: | |
Practice Address - City: | BEMIDJI |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56601-3010 |
Practice Address - Country: | US |
Practice Address - Phone: | 218-751-2020 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-31 |
Last Update Date: | 2012-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 1534 | 152W00000X, 152WC0802X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | |
No | 152WC0802X | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 830723700 | Medicaid | |
MN | 830723700 | Medicaid | |
MN | 410001644 | Medicare ID - Type Unspecified | |
MN | T65477 | Medicare UPIN | |
MN | 410002810 | Medicare PIN |