Provider Demographics
NPI:1669470183
Name:DEITRICK, CHRIS E (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:E
Last Name:DEITRICK
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:PO BOX 1460
Mailing Address - Street 2:101 CASE COMMONS DRIVE
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-1460
Mailing Address - Country:US
Mailing Address - Phone:870-269-3610
Mailing Address - Fax:870-269-5086
Practice Address - Street 1:101 CASE COMMONS DR.
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560
Practice Address - Country:US
Practice Address - Phone:870-269-3610
Practice Address - Fax:870-269-5086
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2516152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR431988740OtherTAX ID #
AR145299722Medicaid
AR4709560001OtherMEDICARE DMEPOS ID #
AR19930000041OtherQUALCHOICE ID #
AR410049416OtherMEDICARE RR ID#
AR145299722Medicaid
AR4709560001OtherMEDICARE DMEPOS ID #