Provider Demographics
NPI:1750304507
Name:HENDRICKSON, JUDITH (OD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:HENDRICKSON
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 1:4592 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:BEECH ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29842-4872
Mailing Address - Country:US
Mailing Address - Phone:803-593-4508
Mailing Address - Fax:803-593-4504
Practice Address - Street 1:4592 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:BEECH ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29842-4872
Practice Address - Country:US
Practice Address - Phone:803-593-4508
Practice Address - Fax:803-593-4504
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU01897Medicare UPIN
GA41ZCFXXMedicare PIN