Provider Demographics
NPI:1669530838
Name:CRYSTAL LAKE OPHTHALMOLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:CRYSTAL LAKE OPHTHALMOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:GEO
Authorized Official - Last Name:DOLEZAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-455-4222
Mailing Address - Street 1:280A MEMORIAL CT
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 1:280A MEMORIAL CT
Practice Address - Street 2:280A MEMORIAL CT
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070162207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070162Medicaid
180038854OtherRAILROAD MEDICARE
IL210954Medicare PIN
D29320Medicare UPIN
180038854OtherRAILROAD MEDICARE
IL036070162Medicaid
IL5359120001Medicare NSC