Provider Demographics
NPI:1063453819
Name:DIERKER, DAMON S (OD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:S
Last Name:DIERKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9202 N MERIDIAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1810
Mailing Address - Country:US
Mailing Address - Phone:317-841-2020
Mailing Address - Fax:317-570-7433
Practice Address - Street 1:9202 N MERIDIAN ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1810
Practice Address - Country:US
Practice Address - Phone:317-841-2020
Practice Address - Fax:317-570-7433
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003170A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200403000Medicaid
IN673220DMedicare ID - Type Unspecified