Provider Demographics
NPI:1063436079
Name:EDWARDS, CHAD J (OD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:J
Last Name:EDWARDS
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 1:12455 E 100TH ST N # 110
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4600
Mailing Address - Country:US
Mailing Address - Phone:918-274-7100
Mailing Address - Fax:918-584-4479
Practice Address - Street 1:12455 E 100TH ST N # 110
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4600
Practice Address - Country:US
Practice Address - Phone:918-274-7100
Practice Address - Fax:918-584-4479
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763950AMedicaid
OK100763950AMedicaid