Provider Demographics
NPI:1992702971
Name:TWEEDY, JEFFREY L (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:TWEEDY
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 1:132 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-1603
Mailing Address - Country:US
Mailing Address - Phone:765-675-6014
Mailing Address - Fax:765-675-6014
Practice Address - Street 1:132 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-1603
Practice Address - Country:US
Practice Address - Phone:765-675-6014
Practice Address - Fax:765-675-6014
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-11-25
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
IN18002354B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200063610BMedicaid
IN1309080001Medicare NSC
INT10521Medicare UPIN
IN200063610BMedicaid