Provider Demographics
NPI:1821179441
Name:DIDAT, JULIE S (OD)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:S
Last Name:DIDAT
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 1:2000 EDSEL LN NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2168
Mailing Address - Country:US
Mailing Address - Phone:812-738-1707
Mailing Address - Fax:812-738-9054
Practice Address - Street 1:2127 EDSEL LN NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2030
Practice Address - Country:US
Practice Address - Phone:812-738-1707
Practice Address - Fax:812-738-9054
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002547A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100116680BMedicaid
IN243460Medicare ID - Type Unspecified
INU27213Medicare UPIN