Provider Demographics
NPI:1700872405
Name:PALOUCEK, JOHN J (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:PALOUCEK
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 1:211 N SPRUCE ST
Mailing Address - Street 2:PO BOX 568
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-2552
Mailing Address - Country:US
Mailing Address - Phone:308-284-4384
Mailing Address - Fax:308-284-4123
Practice Address - Street 1:211 N SPRUCE ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-2552
Practice Address - Country:US
Practice Address - Phone:308-284-4394
Practice Address - Fax:308-284-4123
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065808300Medicaid
U44147Medicare UPIN
NE263089Medicare ID - Type Unspecified