Provider Demographics
NPI:1245276328
Name:EDMONDS, SCOTT A (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:EDMONDS
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 1:3300 TOWNSHIP LINE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1925
Mailing Address - Country:US
Mailing Address - Phone:610-449-2540
Mailing Address - Fax:610-449-2751
Practice Address - Street 1:3300 TOWNSHIP LINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1925
Practice Address - Country:US
Practice Address - Phone:610-449-2540
Practice Address - Fax:610-449-2751
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000492152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1422835OtherAETNA
PA159973OtherBLUE CROSS BLUE SHIELD
PA0062266000OtherKEYSTONE
PA159973KNNMedicare PIN
PA0241340001Medicare NSC
PA410003495Medicare PIN
PA0062266000OtherKEYSTONE