Provider Demographics
NPI:1639467467
Name:DIEP, ETHAN S (OD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:S
Last Name:DIEP
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 1:878 EASTLAKE PKWY STE 1011
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4546
Mailing Address - Country:US
Mailing Address - Phone:619-216-4582
Mailing Address - Fax:619-216-4589
Practice Address - Street 1:878 EASTLAKE PKWY STE 1011
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4546
Practice Address - Country:US
Practice Address - Phone:619-216-4582
Practice Address - Fax:619-216-4589
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist