Provider Demographics
NPI:1255530754
Name:EDWARDS, SAM J JR (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:SAM
Middle Name:J
Last Name:EDWARDS
Suffix:JR
Gender:F
Credentials:OPTICIAN
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Mailing Address - Street 1:1078 CROSSROADS MALL STE D
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-4202
Mailing Address - Country:US
Mailing Address - Phone:405-631-7558
Mailing Address - Fax:405-631-0615
Practice Address - Street 1:1078 CROSSROADS MALL STE D
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149-4202
Practice Address - Country:US
Practice Address - Phone:405-631-7558
Practice Address - Fax:405-631-0615
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2025-06-08
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761320AMedicaid