Provider Demographics
NPI:1154468890
Name:CHESLOCK, GERMAINE E (OD)
Entity Type:Individual
Prefix:
First Name:GERMAINE
Middle Name:E
Last Name:CHESLOCK
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:218-333-2019
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2300152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN942G7CHOtherMN BCBS
1011212OtherPREFERREDONE
MN571725600Medicaid
2204340OtherMEDICA
ND28642OtherND BCBS
HP57666OtherHEALTHPARTNERS
1011212OtherPREFERREDONE
2204340OtherMEDICA
HP57666OtherHEALTHPARTNERS
MN410002805Medicare PIN