Provider Demographics
NPI:1205834926
Name:WIDA, LOIS JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:LOIS
Middle Name:JEAN
Last Name:WIDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2654 N READING RD
Mailing Address - Street 2:
Mailing Address - City:REINHOLDS
Mailing Address - State:PA
Mailing Address - Zip Code:17569-9640
Mailing Address - Country:US
Mailing Address - Phone:717-484-0934
Mailing Address - Fax:
Practice Address - Street 1:2654 N READING RD
Practice Address - Street 2:
Practice Address - City:REINHOLDS
Practice Address - State:PA
Practice Address - Zip Code:17569-9640
Practice Address - Country:US
Practice Address - Phone:717-484-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001242152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00254773OtherRAILROAD MEDICARE
PAP00254773OtherRAILROAD MEDICARE
PAT89398Medicare UPIN