Provider Demographics
NPI:1841423753
Name:DIECKOW, NATHAN CURTIS (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:CURTIS
Last Name:DIECKOW
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 1:1115 N HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2523
Mailing Address - Country:US
Mailing Address - Phone:309-343-1107
Mailing Address - Fax:309-343-1306
Practice Address - Street 1:1115 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2523
Practice Address - Country:US
Practice Address - Phone:309-343-1107
Practice Address - Fax:309-343-1306
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010018379152W00000X
IL046010231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014545OtherMEDICARE PTAN
MO1841423753Medicaid
MO145450010Medicare PIN
MO000014545OtherMEDICARE PTAN