Healthcare Provider Details

I. General information

NPI: 1073882429
Provider Name (Legal Business Name): JENNIFER M GUDAS OD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E 13TH ST
WINAMAC IN
46996-1157
US

IV. Provider business mailing address

633 E 13TH ST PO BOX 365
WINAMAC IN
46996-1157
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-3944
  • Fax: 574-946-6843
Mailing address:
  • Phone: 574-946-3944
  • Fax: 574-946-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003318B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number18003318B
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18003318B
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18003318B
License Number StateIN

VIII. Authorized Official

Name: DR. JENNIFER M GUDAS
Title or Position: OPTOMETRIST
Credential: OD
Phone: 574-946-3944