Provider Demographics
NPI:1811961741
Name:HOGE, EDWARD RUSSELL JR (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:RUSSELL
Last Name:HOGE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 W BLACKWELL ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3555
Mailing Address - Country:US
Mailing Address - Phone:931-455-0654
Mailing Address - Fax:931-455-0669
Practice Address - Street 1:105 W BLACKWELL ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3555
Practice Address - Country:US
Practice Address - Phone:931-455-0654
Practice Address - Fax:931-455-0669
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3592894Medicaid
TNT93667Medicare UPIN
TN3592894Medicaid