Provider Demographics
NPI:1730657388
Name:EDWARDS, JUSTIN ROBERT (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5399 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2265
Mailing Address - Country:US
Mailing Address - Phone:315-468-2745
Mailing Address - Fax:315-468-2786
Practice Address - Street 1:5399 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2265
Practice Address - Country:US
Practice Address - Phone:315-468-2745
Practice Address - Fax:315-468-2786
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC009325156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician