Provider Demographics
NPI:1407836851
Name:DIETTERICK, GARY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:DIETTERICK
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 1:21 CORPORATE DR
Mailing Address - Street 2:STE.#2
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2664
Mailing Address - Country:US
Mailing Address - Phone:610-258-2442
Mailing Address - Fax:610-258-7965
Practice Address - Street 1:21 CORPORATE DR
Practice Address - Street 2:STE.#2
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2664
Practice Address - Country:US
Practice Address - Phone:610-258-2442
Practice Address - Fax:610-258-7965
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3803518OtherAETNA#
PAP00227588OtherPALMETTO GBA RR MEDICARE
PA01776201OtherCAPITAL BC
PA624066OtherBLUE SHIELD
PA180026868OtherRR MEDICARE
PA0255130001Medicare NSC
PAP00227588OtherPALMETTO GBA RR MEDICARE
PA088984Medicare ID - Type UnspecifiedMEDICARE#