Provider Demographics
NPI:1194804583
Name:EDWARDS, NELSON GREY (OD)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:GREY
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 1:136 E GRAND RIVER AVE
Mailing Address - Street 2:PO BOX 618
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-5136
Mailing Address - Country:US
Mailing Address - Phone:517-223-9988
Mailing Address - Fax:517-223-9071
Practice Address - Street 1:136 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-5136
Practice Address - Country:US
Practice Address - Phone:517-223-9988
Practice Address - Fax:517-223-9071
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2770020Medicaid
MI0D76527Medicare PIN
MI2770020Medicaid
MIU19518Medicare UPIN