Provider Demographics
NPI:1194999474
Name:ROGER CHRISTIAN EDE, O.D., INC.
Entity type:Organization
Organization Name:ROGER CHRISTIAN EDE, O.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:EDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-396-6311
Mailing Address - Street 1:377 KEAHOLE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-3405
Mailing Address - Country:US
Mailing Address - Phone:808-396-6311
Mailing Address - Fax:
Practice Address - Street 1:377 KEAHOLE ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-3405
Practice Address - Country:US
Practice Address - Phone:808-396-6311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROGER CHRISTIAN EDE, O.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-17
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0406020001Medicare NSC
HIHREDE003Medicare PIN