Provider Demographics
NPI:1851708572
Name:JUEDES, MICAH (OD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:
Last Name:JUEDES
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 1:950 W RYAN ST
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-1042
Mailing Address - Country:US
Mailing Address - Phone:920-756-2020
Mailing Address - Fax:
Practice Address - Street 1:950 W RYAN ST
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1042
Practice Address - Country:US
Practice Address - Phone:920-756-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3351-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist