Provider Demographics
NPI:1427449354
Name:HENDRICKS, EDWARD SCOTT (OD - OPTOMETRIST)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:SCOTT
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:OD - OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 FIRST. ST.
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559
Mailing Address - Country:US
Mailing Address - Phone:707-226-5446
Mailing Address - Fax:707-226-3772
Practice Address - Street 1:1737 FIRST ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559
Practice Address - Country:US
Practice Address - Phone:707-226-5446
Practice Address - Fax:707-226-3772
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT09506Medicare UPIN