Provider Demographics
NPI:1821045782
Name:DOLEZAL, EDWARD G (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:G
Last Name:DOLEZAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 A MEMORIAL COURT
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6233
Mailing Address - Country:US
Mailing Address - Phone:815-455-4222
Mailing Address - Fax:815-455-5093
Practice Address - Street 1:280 A MEMORIAL COURT
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6233
Practice Address - Country:US
Practice Address - Phone:815-455-4222
Practice Address - Fax:815-455-5093
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070162207W00000X
IL036070162207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070162Medicaid
IL05625795OtherBCBS IL
180038854OtherRAIL ROAD MEDICARE
IL036070162Medicaid
IL210669Medicare PIN
IL05625795OtherBCBS IL
IL210954Medicare PIN