Provider Demographics
NPI:1447267976
Name:EDWARDS, PAUL THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:EDWARDS
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:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-1270
Mailing Address - Country:US
Mailing Address - Phone:804-725-2430
Mailing Address - Fax:804-725-2377
Practice Address - Street 1:75 D MAIN STREET
Practice Address - Street 2:
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109-1270
Practice Address - Country:US
Practice Address - Phone:804-725-2430
Practice Address - Fax:804-725-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009203753Medicaid
VA072708OtherANTHEM BLUE CROSS/BLUE SH
VA0546160001Medicare NSC
VA410000252Medicare ID - Type Unspecified
VA009203753Medicaid