Healthcare Provider Details

I. General information

NPI: 1841395209
Provider Name (Legal Business Name): JENNIFER MARIE GUDAS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 12/14/2011
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

PO BOX 365
WINAMAC IN
46996-0365
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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: