Provider Demographics
NPI:1639177793
Name:WEIDOW, RICKY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LEE
Last Name:WEIDOW
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 1:201 W WAYNE ST
Mailing Address - Street 2:PO BOX 150
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-1850
Mailing Address - Country:US
Mailing Address - Phone:260-463-3421
Mailing Address - Fax:260-463-7347
Practice Address - Street 1:201 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1850
Practice Address - Country:US
Practice Address - Phone:260-463-3421
Practice Address - Fax:260-463-7347
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2010-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002670A/B152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000635212OtherANTHEM BC/BS NWIELC KNOX
IN2604633421OtherVISION SERVICE PLAN LAGRANGE
IN5742334109OtherVISION SERVICE PLAN SOUTH BEND
IN2605932505OtherVISION SERVICE PLAN TOPEKA
IN000000257711OtherANTHEM BC/BS LAGRANGE
IN000000257712OtherANTHEM BC/BS TOPEKA
IN1174740682OtherRENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION TYPE 2 GROUP NPI
IN200097680CMedicaid
IN200097680EMedicaid
IN200097680DMedicaid
IN000000257712OtherANTHEM BC/BS TOPEKA
IN2605932505OtherVISION SERVICE PLAN TOPEKA
IN2604633421OtherVISION SERVICE PLAN LAGRANGE
IN000000635212OtherANTHEM BC/BS NWIELC KNOX
IN200097680CMedicaid
IN410043915Medicare PIN
IN169220AMedicare PIN
IN461830AMedicare PIN
IN169230AMedicare PIN
IN000000257711OtherANTHEM BC/BS LAGRANGE
IN4002320002Medicare NSC
IN461830Medicare PIN