Provider Demographics
NPI:1720181266
Name:CZELUSNIAK, DONALD HENRY (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:HENRY
Last Name:CZELUSNIAK
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:PO BOX 1430
Mailing Address - Street 2:76 SUMMER ST
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-345-3556
Mailing Address - Fax:978-342-9251
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:STE 120
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420
Practice Address - Country:US
Practice Address - Phone:978-345-3556
Practice Address - Fax:978-342-9251
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2164152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0399043Medicaid
MA0399043Medicaid
T59415Medicare UPIN