Provider Demographics
NPI:1689937435
Name:SCDORIS, JOHN CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:SCDORIS
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 1:409 N 78TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3638
Mailing Address - Country:US
Mailing Address - Phone:402-391-6600
Mailing Address - Fax:
Practice Address - Street 1:409 N 78TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3638
Practice Address - Country:US
Practice Address - Phone:402-391-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA2170001Medicare PIN