Individual
DR. RICKY LEE WEIDOW
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
201 W WAYNE ST, LAGRANGE, IN 46761-1850
(260) 463-3421
(260) 463-7347
Mailing address
201 W WAYNE ST, PO BOX 150, LAGRANGE, IN 46761-1850
(260) 463-3421
(260) 463-7347
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18002670A/B
IN
152WC0802X
Corneal and Contact Management Optometrist
18002670A/B
IN
152WP0200X
Pediatric Optometrist
18002670A/B
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000257711
ANTHEM BC/BS LAGRANGE
IN
01
—
000000257712
ANTHEM BC/BS TOPEKA
IN
01
—
000000635212
ANTHEM BC/BS NWIELC KNOX
IN
01
—
1174740682
RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION TYPE 2 GROUP NPI
IN
05
—
200097680C
—
IN
05
—
200097680D
—
IN
05
—
200097680E
—
IN
01
—
2604633421
VISION SERVICE PLAN LAGRANGE
IN
01
—
2605932505
VISION SERVICE PLAN TOPEKA
IN
01
—
5742334109
VISION SERVICE PLAN SOUTH BEND
IN
Enumeration date
07/12/2005
Last updated
02/14/2010
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