Provider Demographics
NPI:1790873370
Name:CHESLOCK, JOHN N (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:CHESLOCK
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 1:950 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2504
Mailing Address - Country:US
Mailing Address - Phone:360-577-1500
Mailing Address - Fax:360-425-0735
Practice Address - Street 1:950 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2504
Practice Address - Country:US
Practice Address - Phone:360-577-1500
Practice Address - Fax:360-425-0735
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0199625OtherLABOR & INDUSTRIES
WA1610999OtherCOMMUNITY HEALTH PLAN
WA2027092Medicaid
WA7048CHOtherREGENCE BLUE CROSS
WA7048CHOtherREGENCE BLUE CROSS
WA1610999OtherCOMMUNITY HEALTH PLAN
WAU92909Medicare UPIN