Healthcare Provider Details

I. General information

NPI: 1699046896
Provider Name (Legal Business Name): JULIE S. DIDAT O.D P.S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2127 EDSEL LN NW
CORYDON IN
47112-2030
US

IV. Provider business mailing address

2127 EDSEL LN NW
CORYDON IN
47112-2030
US

V. Phone/Fax

Practice location:
  • Phone: 812-738-1707
  • Fax: 812-738-9054
Mailing address:
  • Phone: 812-738-1707
  • Fax: 812-738-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002547A
License Number StateIN

VIII. Authorized Official

Name: JAMIE MATTINGLY
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-738-1707