Provider Demographics
NPI:1245317445
Name:JED C WINDER OD, PC
Entity type:Organization
Organization Name:JED C WINDER OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JED
Authorized Official - Middle Name:C
Authorized Official - Last Name:WINDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-882-3233
Mailing Address - Street 1:300 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2746
Mailing Address - Country:US
Mailing Address - Phone:435-882-3233
Mailing Address - Fax:435-882-1626
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2746
Practice Address - Country:US
Practice Address - Phone:435-882-3233
Practice Address - Fax:435-882-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354338-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528869987001Medicaid
UT529296615001Medicaid
UT529296615001Medicaid
UT528869987001Medicaid