Basic Information
| Provider Information | |||||||||
| NPI: | 1619951035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JICHA | ||||||||
| FirstName: | DIANNA | ||||||||
| MiddleName: | POPA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2607 BURCH POINT | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272659333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368693432 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3911 FOUNTAIN GROVE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368892225 | ||||||||
| FaxNumber: | 3368892252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1354 | NC | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 3886 | OH | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0916E | 01 | BCBS | OTHER | 1354 | 01 | NC LICENSE | OTHER | 2337476 | 05 | NC | MEDICAID | 015MC | 01 | BCBS | OTHER | 890914N | 05 | NC | MEDICAID |