MEDICARE: JONATHAN PAUL JUDISCH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	02262	IA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00052944	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	35539	OTHER	IA	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285784280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN PAUL JUDISCH OD

Provider Business Mailing Address
First Line	:	1341 W MAIN ST
Second Line	:	PO BOX 124
City	:	LAKE CITY
State	:	IA
Zip	:	51449-0124
Country	:	US
Telephone Number	:	712-464-3136
Fax Number	:	712-464-7683

Provider Business Practice Location Address
First Line	:	1341 W MAIN ST
Second Line	:
City	:	LAKE CITY
State	:	IA
Zip	:	51449-0124
Country	:	US
Telephone Number	:	712-464-3136
Fax Number	:	712-464-7683

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	01/08/2010

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