Provider Demographics
NPI:1669521027
Name:JUDISCH VISION PC
Entity type:Organization
Organization Name:JUDISCH VISION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JUDISCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-464-3136
Mailing Address - Street 1:1341 W MAIN ST
Mailing Address - Street 2:PO BOX 124
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-0124
Mailing Address - Country:US
Mailing Address - Phone:712-464-3136
Mailing Address - Fax:712-464-7683
Practice Address - Street 1:1341 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-0124
Practice Address - Country:US
Practice Address - Phone:712-464-3136
Practice Address - Fax:712-464-7683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1862152W00000X
IA02262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0258194Medicaid
DA3268OtherRR MEDICARE
25819OtherBCBS
IA25819Medicare PIN
IA0258194Medicaid