Provider Demographics
NPI:1386636744
Name:DIPASQUA, JOSEPH MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:DIPASQUA
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 1:10 HEMINGFORD CIR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4874
Mailing Address - Country:US
Mailing Address - Phone:864-489-6871
Mailing Address - Fax:
Practice Address - Street 1:165 WALTON DR
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-1268
Practice Address - Country:US
Practice Address - Phone:864-489-6871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-21
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9790Medicaid
SCD11752Medicaid
SCDA9790Medicaid