Provider Demographics
NPI:1194843045
Name:THOMAS E BAUER OD AND DIANE S DIBLE OD LLC
Entity Type:Organization
Organization Name:THOMAS E BAUER OD AND DIANE S DIBLE OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-523-5670
Mailing Address - Street 1:1518 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-1167
Mailing Address - Country:US
Mailing Address - Phone:419-523-5670
Mailing Address - Fax:419-523-4025
Practice Address - Street 1:1518 N PERRY ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-1167
Practice Address - Country:US
Practice Address - Phone:419-523-5670
Practice Address - Fax:419-523-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4552 3214152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3916380001Medicare NSC