Provider Demographics
NPI:1568797124
Name:MOTACEK, ADAM (OD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MOTACEK
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 1:1400 10TH AVENUE NE APARTMENT 214
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-2866
Mailing Address - Country:US
Mailing Address - Phone:701-320-5902
Mailing Address - Fax:
Practice Address - Street 1:1300 GATEWAY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3509
Practice Address - Country:US
Practice Address - Phone:701-235-0280
Practice Address - Fax:701-235-3326
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist