Provider Demographics
NPI:1164539821
Name:BIALECKE, THOMAS KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:KENNETH
Last Name:BIALECKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-1237
Mailing Address - Country:US
Mailing Address - Phone:815-732-6966
Mailing Address - Fax:815-732-7613
Practice Address - Street 1:1350 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-284-3935
Practice Address - Fax:815-284-6094
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
612840Medicare ID - Type Unspecified
T37243Medicare UPIN