Provider Demographics
NPI:1376781898
Name:DIANA K OVERBERGER OD INC
Entity Type:Organization
Organization Name:DIANA K OVERBERGER OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:OVERBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-331-4644
Mailing Address - Street 1:30165 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1242
Mailing Address - Country:US
Mailing Address - Phone:440-331-4644
Mailing Address - Fax:440-356-5045
Practice Address - Street 1:21014 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-4305
Practice Address - Country:US
Practice Address - Phone:440-331-4644
Practice Address - Fax:440-356-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9360251Medicare PIN