Provider Demographics
NPI:1144286451
Name:DEJMEK, LINDA MARIE (OD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:DEJMEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S CHAIN DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1437
Mailing Address - Country:US
Mailing Address - Phone:920-733-3629
Mailing Address - Fax:920-731-8089
Practice Address - Street 1:509 S CHAIN DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1437
Practice Address - Country:US
Practice Address - Phone:920-733-3629
Practice Address - Fax:920-731-8089
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT61751Medicare UPIN
WI000047240Medicare ID - Type Unspecified
WI0580760001Medicare NSC