Provider Demographics
NPI:1881754646
Name:PERSONETT, CHAD D (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:D
Last Name:PERSONETT
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 1:1867 AIRPORT WAY
Mailing Address - Street 2:SUITE 150-A
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4007
Mailing Address - Country:US
Mailing Address - Phone:907-452-2131
Mailing Address - Fax:907-452-2618
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:SUITE 150-A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4007
Practice Address - Country:US
Practice Address - Phone:907-452-2131
Practice Address - Fax:907-452-2618
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA 193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7731257OtherAETNA
AK101205500OtherDEPT OF LABOR
AKN2402OtherBLUE CROSS BLUE SHIELD
AKOD3575Medicaid
AKOD3575Medicaid