Provider Demographics
NPI:1609883800
Name:EDEWAARD, BARRY A (OD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:A
Last Name:EDEWAARD
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 1:17521 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1768
Mailing Address - Country:US
Mailing Address - Phone:850-674-2020
Mailing Address - Fax:850-674-4801
Practice Address - Street 1:17521 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1768
Practice Address - Country:US
Practice Address - Phone:850-674-2020
Practice Address - Fax:850-674-4801
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19030Medicare ID - Type UnspecifiedPROVIDER NUMBER