Provider Demographics
NPI:1730103946
Name:FRIES-BALOG, DIANE G (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:G
Last Name:FRIES-BALOG
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 1:531 N CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-4602
Mailing Address - Country:US
Mailing Address - Phone:610-323-0450
Mailing Address - Fax:
Practice Address - Street 1:531 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-4602
Practice Address - Country:US
Practice Address - Phone:610-323-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001588152W00000X
NJ27OA00519300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PANJ1588OtherEYEMED
PA766110OtherHIGHMARK BC/BS
PAPA77433-1OtherVISION BENEFITS OF AMERICA (VBA)
PA0018193600003Medicaid
PA4390338OtherAETNA PPO
PA1105628OtherAETNA HMO
PA55470OtherDAVISVISION
PA1105628OtherAETNA HMO
PAPA77433-1OtherVISION BENEFITS OF AMERICA (VBA)