Provider Demographics
NPI:1083705826
Name:DEIBOLDT, MICHAEL J (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DEIBOLDT
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 1:420 W JUBAL EARLY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6435
Mailing Address - Country:US
Mailing Address - Phone:540-662-2700
Mailing Address - Fax:540-662-8801
Practice Address - Street 1:420 W JUBAL EARLY DR STE 200
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6435
Practice Address - Country:US
Practice Address - Phone:540-662-2700
Practice Address - Fax:540-662-8801
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0681800575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00W222A02Medicare PIN
VAU85921Medicare UPIN