Provider Demographics
NPI:1922078278
Name:CHADDERDON, ABIE R (OD)
Entity Type:Individual
Prefix:DR
First Name:ABIE
Middle Name:R
Last Name:CHADDERDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E MAIN ST
Mailing Address - Street 2:PO BOX 773
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-0773
Mailing Address - Country:US
Mailing Address - Phone:641-752-1511
Mailing Address - Fax:641-753-8773
Practice Address - Street 1:501 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-0773
Practice Address - Country:US
Practice Address - Phone:641-752-1511
Practice Address - Fax:641-753-8773
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1229641Medicaid
IAI20102Medicare PIN
IAT01311Medicare UPIN
IA5961790001Medicare NSC