Provider Demographics
NPI:1497815278
Name:MARK A. JUDD, OD PA
Entity Type:Organization
Organization Name:MARK A. JUDD, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:AISTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-792-8733
Mailing Address - Street 1:1701 STATE ROAD 96
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3014
Mailing Address - Country:US
Mailing Address - Phone:620-792-8733
Mailing Address - Fax:620-792-3621
Practice Address - Street 1:1701 STATE ROAD 96
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3014
Practice Address - Country:US
Practice Address - Phone:620-792-8733
Practice Address - Fax:620-792-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1484-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100280160DMedicaid
KS100280160DMedicaid
KS65133Medicare PIN
KS5627390001Medicare NSC