Provider Demographics
NPI:1316931710
Name:SCARBROUGH, EDWARD L (OD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:SCARBROUGH
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 1:527 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2207
Mailing Address - Country:US
Mailing Address - Phone:231-947-8667
Mailing Address - Fax:231-947-3180
Practice Address - Street 1:527 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2207
Practice Address - Country:US
Practice Address - Phone:231-947-8667
Practice Address - Fax:231-947-3180
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B86520Medicare ID - Type Unspecified
MIU28860Medicare UPIN
MIB86520001Medicare PIN