Provider Demographics
NPI:1558382986
Name:EDGECOMB, CORYDON G (OD)
Entity Type:Individual
Prefix:MR
First Name:CORYDON
Middle Name:G
Last Name:EDGECOMB
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1287 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5805
Mailing Address - Country:US
Mailing Address - Phone:530-622-7660
Mailing Address - Fax:530-622-3753
Practice Address - Street 1:1287 BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5805
Practice Address - Country:US
Practice Address - Phone:530-622-7660
Practice Address - Fax:530-622-3753
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA4245T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS00042450Medicaid
CA0936030001Medicare NSC
T09607Medicare UPIN
CAS00042450Medicaid