Provider Demographics
NPI:1194094441
Name:FUTCH, EDWARD DANIEL (LICENSED OPTICIAN)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:DANIEL
Last Name:FUTCH
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 WEST MERCURY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-3103
Mailing Address - Country:US
Mailing Address - Phone:757-827-3960
Mailing Address - Fax:757-827-3960
Practice Address - Street 1:2501 WEST MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3103
Practice Address - Country:US
Practice Address - Phone:757-827-3960
Practice Address - Fax:757-827-3960
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101002476156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician