Provider Demographics
NPI:1811944085
Name:EDMONDS, SUSAN E (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:EDMONDS
Suffix:
Gender:F
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:2006-05-31
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000493152W00000X, 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
PA429782OtherBLUE CROSS/ BLUE SHIELD
PA0033165000OtherKEYSTONE
PA2545643OtherAETNA
PA0241340001Medicare NSC
PA429782KNNMedicare PIN
PA429782OtherBLUE CROSS/ BLUE SHIELD
PA0033165000OtherKEYSTONE