Provider Demographics
NPI:1124052626
Name:KOLODZIEJCZYK, JASON R (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:KOLODZIEJCZYK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 W HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420
Mailing Address - Country:US
Mailing Address - Phone:419-334-8121
Mailing Address - Fax:419-332-9351
Practice Address - Street 1:2311 HAYES AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2634
Practice Address - Country:US
Practice Address - Phone:419-334-8121
Practice Address - Fax:419-332-9351
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2677214Medicaid
V09805Medicare UPIN
4184621Medicare PIN