Provider Demographics
NPI:1689931784
Name:J. EDGAR EVANS O.D., INC.
Entity type:Organization
Organization Name:J. EDGAR EVANS O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-384-2015
Mailing Address - Street 1:11 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1255
Mailing Address - Country:US
Mailing Address - Phone:740-384-2015
Mailing Address - Fax:740-384-5634
Practice Address - Street 1:11 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1255
Practice Address - Country:US
Practice Address - Phone:740-384-2015
Practice Address - Fax:740-384-5634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J. EDGAR EVANS O.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2942/T1049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0235445Medicaid
OH0412492Medicare PIN
OHT46736Medicare UPIN