Provider Demographics
NPI:1679620587
Name:KOLSTAD, JON C (OD PC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:KOLSTAD
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MT
Mailing Address - Zip Code:59230-2407
Mailing Address - Country:US
Mailing Address - Phone:406-228-8641
Mailing Address - Fax:406-228-2094
Practice Address - Street 1:630 3RD AVE S
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MT
Practice Address - Zip Code:59230-2407
Practice Address - Country:US
Practice Address - Phone:406-228-8641
Practice Address - Fax:406-228-2094
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000480012Medicaid
MT0000482647Medicaid
MT0000483565Medicaid
MT0000482647Medicaid
MT000082587Medicare ID - Type Unspecified
MT000082588Medicare ID - Type Unspecified
MT0000483565Medicaid
MT0000482647Medicaid