Healthcare Provider Details

I. General information

NPI: 1639177793
Provider Name (Legal Business Name): RICKY LEE WEIDOW O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 02/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W WAYNE ST
LAGRANGE IN
46761-1850
US

IV. Provider business mailing address

201 W WAYNE ST PO BOX 150
LAGRANGE IN
46761-1850
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-3421
  • Fax: 260-463-7347
Mailing address:
  • Phone: 260-463-3421
  • Fax: 260-463-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002670A/B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number18002670A/B
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18002670A/B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: