Provider Demographics
NPI:1629117023
Name:DOLEZAL, JOSEPH L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:L
Last Name:DOLEZAL
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 1:1125 MELLEN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1173
Mailing Address - Country:US
Mailing Address - Phone:360-736-7385
Mailing Address - Fax:360-736-8568
Practice Address - Street 1:1125 MELLEN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1173
Practice Address - Country:US
Practice Address - Phone:360-736-7385
Practice Address - Fax:360-736-8568
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0499920001Medicare NSC