Provider Demographics
NPI:1699719112
Name:WARREN, EDWARD C JR (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:C
Last Name:WARREN
Suffix:JR
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 1:155 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-7029
Mailing Address - Country:US
Mailing Address - Phone:603-448-2111
Mailing Address - Fax:603-448-2443
Practice Address - Street 1:24 HANOVER ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1334
Practice Address - Country:US
Practice Address - Phone:603-448-2111
Practice Address - Fax:603-448-2443
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT30-0000233152W00000X
NH0464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003749Medicaid
VT0005950Medicaid
VT0005950Medicaid
NH30003749Medicaid