Provider Demographics
NPI:1679629521
Name:EDICK, JAMES LAURENCE (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LAURENCE
Last Name:EDICK
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 1:5 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3282
Mailing Address - Country:US
Mailing Address - Phone:740-397-3355
Mailing Address - Fax:740-397-2843
Practice Address - Street 1:5 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3282
Practice Address - Country:US
Practice Address - Phone:740-397-3355
Practice Address - Fax:740-397-2843
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0850431Medicaid
OH0850431Medicaid
OHED0606126Medicare ID - Type Unspecified
OH0606126Medicare PIN