MEDICARE: KAREN WELDON NEIDICH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1982753265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN WELDON NEIDICH O.D.

Provider Business Mailing Address
First Line	:	1105 BUTLER RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-4702
Country	:	US
Telephone Number	:	815-332-5784
Fax Number	:

Provider Business Practice Location Address
First Line	:	8750 N 2ND ST
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-2080
Country	:	US
Telephone Number	:	815-877-0016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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