Provider Demographics
NPI:1073882429
Name:JENNIFER M GUDAS OD, PC
Entity Type:Organization
Organization Name:JENNIFER M GUDAS OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUDAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-946-3944
Mailing Address - Street 1:633 E 13TH ST
Mailing Address - Street 2:PO BOX 365
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1157
Mailing Address - Country:US
Mailing Address - Phone:574-946-3944
Mailing Address - Fax:574-946-6843
Practice Address - Street 1:633 E 13TH ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1157
Practice Address - Country:US
Practice Address - Phone:574-946-3944
Practice Address - Fax:574-946-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003318B152W00000X, 152WC0802X, 152WP0200X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty