Provider Demographics
NPI:1679883912
Name:CZAJA, JOHN PETER (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PETER
Last Name:CZAJA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8100 BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6215
Mailing Address - Country:US
Mailing Address - Phone:219-769-2020
Mailing Address - Fax:219-756-8937
Practice Address - Street 1:8100 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6215
Practice Address - Country:US
Practice Address - Phone:219-769-2020
Practice Address - Fax:219-756-8937
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002875A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200866690AMedicaid
IN200866690AMedicaid
IN161690Medicare PIN