Provider Demographics
NPI:1518343763
Name:NATHANIEL D EDWARDS OD PLLC
Entity Type:Organization
Organization Name:NATHANIEL D EDWARDS OD PLLC
Other - Org Name:EDWARDS FAMILY VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-255-1172
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200600380AMedicaid