Provider Demographics
NPI:1427103902
Name:JUDISCH VISION PC
Entity type:Organization
Organization Name:JUDISCH VISION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JUDISCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-657-3304
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:1160 3RD ST
Mailing Address - City:LAKE VIEW
Mailing Address - State:IA
Mailing Address - Zip Code:51450-0080
Mailing Address - Country:US
Mailing Address - Phone:712-657-3304
Mailing Address - Fax:712-657-3303
Practice Address - Street 1:1160 3RD ST
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:IA
Practice Address - Zip Code:51450-0080
Practice Address - Country:US
Practice Address - Phone:712-657-3304
Practice Address - Fax:712-657-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
25818OtherBCBS
IA0258194Medicaid
DA3270OtherRR MEDICARE
IA0387350003Medicare NSC
IA25818Medicare PIN