Provider Demographics
NPI:1790741809
Name:DALECKY, PAUL R (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:DALECKY
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 1:16800 W CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:
Practice Address - Street 1:1920 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5310
Practice Address - Country:US
Practice Address - Phone:414-325-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI 1709OtherEYEMED VISION NO.
T61723Medicare UPIN