Provider Demographics
NPI:1285784280
Name:JUDISCH, JONATHAN PAUL (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PAUL
Last Name:JUDISCH
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 1:1341 W MAIN ST
Mailing Address - Street 2:PO BOX 124
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-0124
Mailing Address - Country:US
Mailing Address - Phone:712-464-3136
Mailing Address - Fax:712-464-7683
Practice Address - Street 1:1341 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-0124
Practice Address - Country:US
Practice Address - Phone:712-464-3136
Practice Address - Fax:712-464-7683
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025030700Medicaid
IA35539OtherBCBS
IA0418657Medicaid
P00052944OtherRR MEDICARE
U96062Medicare UPIN
IAI10143Medicare PIN
P00052944OtherRR MEDICARE
IAI10142Medicare PIN