Provider Demographics
NPI:1598889891
Name:DI GIACOMO, QUINT (OD)
Entity Type:Individual
Prefix:DR
First Name:QUINT
Middle Name:
Last Name:DI GIACOMO
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 1:10025 E DYNAMITE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-3688
Mailing Address - Country:US
Mailing Address - Phone:480-419-7778
Mailing Address - Fax:480-419-7779
Practice Address - Street 1:112 W HILL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6218
Practice Address - Country:US
Practice Address - Phone:505-722-2289
Practice Address - Fax:505-726-6208
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2281152W00000X
AZ01246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP0516Medicaid
NM2591225Medicare ID - Type Unspecified
NMP0516Medicaid
NMT74974Medicare UPIN