MEDICARE: DR. PAUL R DALECKY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1709	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WI 1709	OTHER		EYEMED VISION NO.

General Provider Information

NPI Number	:	1790741809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL R DALECKY O.D.

Provider Business Mailing Address
First Line	:	16800 W CLEVELAND AVE
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-3533
Country	:	US
Telephone Number	:	262-432-2005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 W LAYTON AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-5310
Country	:	US
Telephone Number	:	414-325-8600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	01/08/2008

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