Provider Demographics
NPI:1700136199
Name:JON C KOLSTAD OD, PC
Entity Type:Organization
Organization Name:JON C KOLSTAD OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOLSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:406-228-8641
Mailing Address - Street 1:630 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MT
Mailing Address - Zip Code:59230-2407
Mailing Address - Country:US
Mailing Address - Phone:406-228-8641
Mailing Address - Fax:406-228-2094
Practice Address - Street 1:630 3RD AVE S
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MT
Practice Address - Zip Code:59230-2407
Practice Address - Country:US
Practice Address - Phone:406-228-8641
Practice Address - Fax:406-228-2094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT616MT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1639361058Medicaid
MT000082587Medicare PIN
MTU58391Medicare UPIN