Provider Demographics
NPI:1700937489
Name:EDWARDS, ROBERT RANDAL (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDAL
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:RANDAL
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:951 N MILLIKEN AVE
Mailing Address - Street 2:INSIDE SAM'S CLUB
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5008
Mailing Address - Country:US
Mailing Address - Phone:909-481-9801
Mailing Address - Fax:909-987-4956
Practice Address - Street 1:951 N MILLIKEN AVE
Practice Address - Street 2:INSIDE SAM'S CLUB
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5008
Practice Address - Country:US
Practice Address - Phone:909-481-9801
Practice Address - Fax:909-987-4956
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6206152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU52507Medicare UPIN