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General NPI Number Information
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NPI Number | 1669530838
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Entity Type | Organization
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Legal Business Name | CRYSTAL LAKE OPHTHALMOLOGY ASSOCIATES PC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 02/28/2011
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Provider Practice Location Address
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Address Line | 280A MEMORIAL CT 280A MEMORIAL CT
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-6233
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Country | US
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Telephone | 815-455-4222
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Fax | 815-455-5093
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Provider Business Mailing Address
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Address Line | 280A MEMORIAL CT
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-6233
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Country | US
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Telephone | 815-455-4222
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Fax | 815-455-5093
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | EDWARD GEO DOLEZAL
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Credential | MD
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Telephone | 815-455-4222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 036070162
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License Number State | IL
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