Provider Demographics
NPI:1275530677
Name:MCCORMICK, CHESTER J (OD)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:J
Last Name:MCCORMICK
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 1:331 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-1880
Mailing Address - Country:US
Mailing Address - Phone:402-376-2005
Mailing Address - Fax:
Practice Address - Street 1:331 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1880
Practice Address - Country:US
Practice Address - Phone:402-376-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47069616600Medicaid
NE410011039OtherRAILROAD MEDICARE
NE410011039OtherRAILROAD MEDICARE
NE87558MCMedicare PIN
NET80122Medicare UPIN