Provider Demographics
NPI:1841395209
Name:GUDAS, JENNIFER MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:GUDAS
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-0365
Mailing Address - Country:US
Mailing Address - Phone:574-946-3944
Mailing Address - Fax:574-946-6843
Practice Address - Street 1:633 E 13TH ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1157
Practice Address - Country:US
Practice Address - Phone:574-946-3944
Practice Address - Fax:574-946-6843
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003318B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200494530Medicaid
INV01843Medicare UPIN
IN200494530Medicaid