Provider Demographics
NPI:1053303198
Name:HEDRICK, JACK T (OD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:HEDRICK
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 1:600 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-1040
Mailing Address - Country:US
Mailing Address - Phone:812-883-2700
Mailing Address - Fax:812-883-2752
Practice Address - Street 1:600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-1040
Practice Address - Country:US
Practice Address - Phone:812-883-2700
Practice Address - Fax:812-883-2752
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001316A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000350877OtherANTHEM BCBS
IN18001316AOtherOD LICENSE NUMBER
IN100279520Medicaid
IN221390BMedicare PIN
T35212Medicare UPIN
IN5419240006Medicare NSC