Provider Demographics
NPI:1659374361
Name:EDGE, ROBERT EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:EDGE
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 1:2880 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2457
Mailing Address - Country:US
Mailing Address - Phone:251-470-8820
Mailing Address - Fax:251-470-8943
Practice Address - Street 1:1206 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2407
Practice Address - Country:US
Practice Address - Phone:251-246-3231
Practice Address - Fax:251-246-3034
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS412TA033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2210129OtherUNITED HEALTHCARE PROV #
AL4386054OtherAETNA PROVIDER #
ALT69193OtherHEALTHSPRING PROVIDER #
AL51076025OtherBLUE CROSS OF AL PROV #
ALT69193OtherHEALTHSPRING PROVIDER #