Basic Information
| Provider Information | |||||||||
| NPI: | 1891148151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIELEMAN | ||||||||
| FirstName: | MACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FICKBOHM | ||||||||
| OtherFirstName: | MACY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 718 STORY ST | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500362834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154322020 | ||||||||
| FaxNumber: | 5154328482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 083098 | IA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1219526 | 05 | IA | MEDICAID |