Provider Demographics
NPI:1013795343
Name:EDMONDS, ISAIAH SCOTT (LDO)
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:SCOTT
Last Name:EDMONDS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8830
Mailing Address - Country:US
Mailing Address - Phone:912-537-2436
Mailing Address - Fax:912-537-2659
Practice Address - Street 1:3109 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-2436
Practice Address - Fax:912-537-2659
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002780156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician