Provider Demographics
NPI:1821059940
Name:EDWARDS, JOHN D (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:EDWARDS
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:PO BOX 624
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-0624
Mailing Address - Country:US
Mailing Address - Phone:580-225-1980
Mailing Address - Fax:580-225-8648
Practice Address - Street 1:101 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5231
Practice Address - Country:US
Practice Address - Phone:580-225-1980
Practice Address - Fax:580-225-8648
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731122948002OtherDEPT OF REHABILITATIVE SE
OK410027999OtherRAILROAD PROVIDER #
OK100759880BMedicaid
OK731122948002OtherBLUE CROSS BLUE SHIELD
OK242412500Medicare ID - Type UnspecifiedMEDICARE