Provider Demographics
NPI:1760477228
Name:GUDEMAN, JONATHAN ALAN (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALAN
Last Name:GUDEMAN
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 1:101 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3638
Mailing Address - Country:US
Mailing Address - Phone:540-387-1183
Mailing Address - Fax:
Practice Address - Street 1:101 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3638
Practice Address - Country:US
Practice Address - Phone:540-387-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA461361OtherANTHEM
VA410049826OtherPALMETTO GBA
VA9237216Medicaid
VA4715110001OtherADMINISTAR FEDERAL
VAU63542Medicare UPIN
VA00V184E95Medicare PIN