Provider Demographics
NPI:1215129531
Name:DAVID S. EDMONDS OD PC
Entity type:Organization
Organization Name:DAVID S. EDMONDS OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-537-2436
Mailing Address - Street 1:3109 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8830
Mailing Address - Country:US
Mailing Address - Phone:912-537-2436
Mailing Address - Fax:912-537-2659
Practice Address - Street 1:3109 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-2436
Practice Address - Fax:912-537-2659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002008152W00000X
WV975-OD152W00000X
OH5027-T1904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA496302301AMedicaid
GAU79324Medicare UPIN
GA511G700517Medicare PIN
GA41ZCFZBMedicare PIN