Healthcare Provider Details

I. General information

NPI: 1427103902
Provider Name (Legal Business Name): JUDISCH VISION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 3RD ST
LAKE VIEW IA
51450-0080
US

IV. Provider business mailing address

PO BOX 80 1160 3RD ST
LAKE VIEW IA
51450-0080
US

V. Phone/Fax

Practice location:
  • Phone: 712-657-3304
  • Fax: 712-657-3303
Mailing address:
  • Phone: 712-657-3304
  • Fax: 712-657-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02262
License Number StateIA

VIII. Authorized Official

Name: JONATHAN PAUL JUDISCH
Title or Position: PRESIDENT
Credential: OD
Phone: 712-657-3304