Provider Demographics
NPI:1215035795
Name:DEIBERT, CHRISTOPHER R (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:DEIBERT
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 1:30 COTTAGE DR
Mailing Address - Street 2:
Mailing Address - City:LURAY
Mailing Address - State:VA
Mailing Address - Zip Code:22835-9201
Mailing Address - Country:US
Mailing Address - Phone:540-743-5670
Mailing Address - Fax:540-743-2342
Practice Address - Street 1:30 COTTAGE DR
Practice Address - Street 2:
Practice Address - City:LURAY
Practice Address - State:VA
Practice Address - Zip Code:22835-9201
Practice Address - Country:US
Practice Address - Phone:540-743-5670
Practice Address - Fax:540-743-2342
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000037152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009230343Medicaid
VA410000416Medicare PIN
VA0303600001Medicare NSC
VA009230343Medicaid