Basic Information
| Provider Information | |||||||||
| NPI: | 1174706642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAREL C. EDWARDS, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIDALIA EYECARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9125377935 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9125377935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | DAREL | ||||||||
| AuthorizedOfficialMiddleName: | CALVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9125372020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1223 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1639162175 | 01 | GA | NPI INDIVIDUAL | OTHER | 00423893G | 05 | GA | MEDICAID | GRP3934 | 01 | GA | MEDICARE GROUP NUMBER | OTHER |