Provider Demographics
NPI:1447875463
Name:EDMUND, ALEXANDRA KATHRYN (OD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KATHRYN
Last Name:EDMUND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:KATHRYN
Other - Last Name:BUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-8164
Practice Address - Country:US
Practice Address - Phone:203-924-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT003165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program