Provider Demographics
NPI:1467897611
Name:DIETMEIER, BOKAYE M (OD)
Entity Type:Individual
Prefix:
First Name:BOKAYE
Middle Name:M
Last Name:DIETMEIER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HILLCREST LN
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2675
Mailing Address - Country:US
Mailing Address - Phone:815-990-6968
Mailing Address - Fax:
Practice Address - Street 1:425 W WASHINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2738
Practice Address - Country:US
Practice Address - Phone:608-256-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3294-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61417OtherDEAN HEALTH INSURANCE
WI478100013Medicare PIN
WI478050027Medicare PIN
WI477950010Medicare PIN
WI61417OtherDEAN HEALTH INSURANCE
WI741501985Medicare PIN
WI543401725Medicare PIN
WI478100013Medicare PIN
WI570850237Medicare PIN