Provider Demographics
NPI:1619951035
Name:JICHA, DIANNA POPA (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:POPA
Last Name:JICHA
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 1:2607 BURCH POINT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9333
Mailing Address - Country:US
Mailing Address - Phone:336-869-3432
Mailing Address - Fax:
Practice Address - Street 1:3911 FOUNTAIN GROVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8032
Practice Address - Country:US
Practice Address - Phone:336-889-2225
Practice Address - Fax:336-889-2252
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1354152W00000X
OH3886152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0916EOtherBCBS
1354OtherNC LICENSE
NC2337476Medicaid
015MCOtherBCBS
NC890914NMedicaid
NC890914NMedicaid
1354OtherNC LICENSE
U17482Medicare UPIN