Provider Demographics
NPI:1689725582
Name:JUDISCH VISION PC
Entity Type:Organization
Organization Name:JUDISCH VISION PC
Other - Org Name:ROCK JUDISCH VISION CLINIC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JUDISCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-464-3136
Mailing Address - Street 1:1800 MAIN ST
Mailing Address - Street 2:PO BOX 102
Mailing Address - City:GOWRIE
Mailing Address - State:IA
Mailing Address - Zip Code:50543-0102
Mailing Address - Country:US
Mailing Address - Phone:515-352-3881
Mailing Address - Fax:515-352-3624
Practice Address - Street 1:1800 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOWRIE
Practice Address - State:IA
Practice Address - Zip Code:50543-0102
Practice Address - Country:US
Practice Address - Phone:515-352-3881
Practice Address - Fax:515-352-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0258194Medicaid
IA25817OtherBCBS
IADA3271OtherRR MEDICARE
IA0258194Medicaid
IADA3271OtherRR MEDICARE