Basic Information
| Provider Information | |||||||||
| NPI: | 1154380673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEDRICH | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168 | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469520168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656646148 | ||||||||
| FaxNumber: | 7656649782 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656646148 | ||||||||
| FaxNumber: | 7656649782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18002338A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1000094740 | 05 | IN | MEDICAID |