NPIMap

Organization Active NPI

Crystal Lake Ophthalmology Associates PC

  • Ophthalmology Physician
  • Crystal Lake, IL
National Provider Identifier
1669530838
Registry record updated Feb 28, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
036070162 Issued in IL
Legal business name
CRYSTAL LAKE OPHTHALMOLOGY ASSOCIATES PC
Practice address
280A Memorial CT
280A Memorial CT
Crystal Lake, IL 60014-6233
Phone
(815) 455-4222
Fax
(815) 455-5093
NPI assigned
Dec 4, 2006
Last updated
Feb 28, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edward Geo Dolezal, MDNPI 1821045782
Title
Physician Owner
Phone
(815) 455-4222

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207W00000X 036070162 IL Primary

Addresses

Primary practice location

280A Memorial CT
280A Memorial CT
Crystal Lake, IL 60014-6233

Mailing address

280A Memorial CT
Crystal Lake, IL 60014-6233
Phone (815) 455-4222

Other identifiers 2

IdentifierTypeStateIssuer
036070162MedicaidIL
180038854OtherRAILROAD MEDICARE

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1298851200000",
    "number": "1669530838",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "280A MEMORIAL CT",
            "city": "CRYSTAL LAKE",
            "state": "IL",
            "postal_code": "600146233",
            "telephone_number": "815-455-4222",
            "fax_number": "815-455-5093"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "280A MEMORIAL CT",
            "address_2": "280A MEMORIAL CT",
            "city": "CRYSTAL LAKE",
            "state": "IL",
            "postal_code": "600146233",
            "telephone_number": "815-455-4222",
            "fax_number": "815-455-5093"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL LAKE OPHTHALMOLOGY ASSOCIATES PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-04",
        "last_updated": "2011-02-28",
        "status": "A",
        "authorized_official_last_name": "DOLEZAL",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_middle_name": "GEO",
        "authorized_official_title_or_position": "PHYSICIAN OWNER",
        "authorized_official_telephone_number": "815-455-4222",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "IL",
            "license": "036070162",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036070162",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "180038854",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Crystal Lake, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.