=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801859228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMMIE MARIE CHIZEK OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2006
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1875 MIDDLE RD
-----------------------------------------------------
City | BETTENDORF
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52722-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-359-4446
-----------------------------------------------------
Fax | 563-359-0381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 S 8TH AVE
-----------------------------------------------------
City | ELDRIDGE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52748-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-285-6855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 02286
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------