Healthcare Provider Details

I. General information

NPI: 1861621104
Provider Name (Legal Business Name): BEN JOSEPH JUDSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 SW 4TH AVE
ONTARIO OR
97914-4516
US

IV. Provider business mailing address

1257 SW 4TH AVE
ONTARIO OR
97914-4516
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2191
  • Fax: 541-881-1523
Mailing address:
  • Phone: 541-889-2191
  • Fax: 541-881-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP100198
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3309ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: