Healthcare Provider Details

I. General information

NPI: 1679883912
Provider Name (Legal Business Name): JOHN PETER CZAJA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 BROADWAY SUITE A
MERRILLVILLE IN
46410-6215
US

IV. Provider business mailing address

8100 BROADWAY SUITE A
MERRILLVILLE IN
46410-6215
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-2020
  • Fax: 219-756-8937
Mailing address:
  • Phone: 219-769-2020
  • Fax: 219-756-8937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002875A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: