Provider Demographics
NPI:1407867245
Name:DIETERICHS, DANIEL JOHN (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:DIETERICHS
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 1:1606 JACK NICKLAUS DR
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-5925
Mailing Address - Country:US
Mailing Address - Phone:505-450-5343
Mailing Address - Fax:
Practice Address - Street 1:3701 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3536
Practice Address - Country:US
Practice Address - Phone:505-298-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201014237OtherPRESBYTERIAN NEW MEXICO
NMDA6066OtherRAILROAD MEDICARE GROUP
NM410049648OtherRAILROAD MEDICARE INDIVID
NM4991500001OtherDMERC
NMNM00P502OtherBLUE CROSS AND BLUE SHIEL
NM000E8983Medicaid
NM410049648OtherRAILROAD MEDICARE INDIVID
NM4991500001OtherDMERC