Provider Demographics
NPI:1285799650
Name:KREZELOK, CHAD (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:KREZELOK
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 1:17 E STORY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4881
Mailing Address - Country:US
Mailing Address - Phone:307-752-7118
Mailing Address - Fax:
Practice Address - Street 1:1500 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2557
Practice Address - Country:US
Practice Address - Phone:406-585-8153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT28461Medicare UPIN