Basic Information
| Provider Information | |||||||||
| NPI: | 1053404756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLUDT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015676130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015676133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0504 | ND | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 11201 | 01 | ND BC/BS | OTHER | 9202430 | 05 | SD | MEDICAID | 480545 | 05 | MT | MEDICAID | 800504 | 01 | ND BC VISION | OTHER | 60435 | 05 | ND | MEDICAID |