Provider Demographics
NPI:1114134558
Name:KOLODZEY, ELIZABETH ANN (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:KOLODZEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 CHANCE MOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2826
Mailing Address - Country:US
Mailing Address - Phone:619-934-1705
Mailing Address - Fax:
Practice Address - Street 1:2850 WOMBLE RD
Practice Address - Street 2:SUITE #106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6155
Practice Address - Country:US
Practice Address - Phone:619-523-9990
Practice Address - Fax:619-523-9847
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12315T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGP886AMedicare PIN