Provider Demographics
NPI:1184608499
Name:SNODGRASS, JANE A (OD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:SNODGRASS
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 1:1250 NW 128TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7432
Mailing Address - Country:US
Mailing Address - Phone:515-223-9595
Mailing Address - Fax:515-223-9792
Practice Address - Street 1:1250 NW 128TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7432
Practice Address - Country:US
Practice Address - Phone:515-223-9595
Practice Address - Fax:515-223-9792
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA 1994152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10641Medicare PIN