Provider Demographics
NPI:1699046896
Name:JULIE S. DIDAT O.D P.S.C
Entity type:Organization
Organization Name:JULIE S. DIDAT O.D P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-738-1707
Mailing Address - Street 1:2127 EDSEL LN NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2030
Mailing Address - Country:US
Mailing Address - Phone:812-738-1707
Mailing Address - Fax:812-738-9054
Practice Address - Street 1:2127 EDSEL LN NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2030
Practice Address - Country:US
Practice Address - Phone:812-738-1707
Practice Address - Fax:812-738-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002547A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100116680BMedicaid
IN100116680BMedicaid