Provider Demographics
NPI:1063486124
Name:DEJONG, CRAIG D (OD)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:D
Last Name:DEJONG
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:24 1ST ST SE
Mailing Address - Street 2:GLACIAL RIDGE EYE CLINIC, INC
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1619
Mailing Address - Country:US
Mailing Address - Phone:320-634-4516
Mailing Address - Fax:320-634-4520
Practice Address - Street 1:24 1ST ST SE
Practice Address - Street 2:GLACIAL RIDGE EYE CLINIC, INC
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1619
Practice Address - Country:US
Practice Address - Phone:320-634-4516
Practice Address - Fax:320-634-4520
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-09-06
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Provider Licenses
StateLicense IDTaxonomies
MN2027152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65451Medicare UPIN