Provider Demographics
NPI:1427281583
Name:CZYWCZYNSKI, DEREK DAVID (OD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:DAVID
Last Name:CZYWCZYNSKI
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 1:104 12TH AVE NW
Mailing Address - Street 2:SUITE #1
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4100
Mailing Address - Country:US
Mailing Address - Phone:701-748-5220
Mailing Address - Fax:701-748-5221
Practice Address - Street 1:104 12TH AVE NW
Practice Address - Street 2:SUITE #1
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4100
Practice Address - Country:US
Practice Address - Phone:701-748-5220
Practice Address - Fax:701-748-5221
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1340152W00000X
ND681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60698Medicaid
ND893357OtherNORTH DAKOTA VISION SERVICES
ND893357OtherNORTH DAKOTA VISION SERVICES