Provider Demographics
NPI:1902855414
Name:DIETELS, GUY ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:GUY
Middle Name:ANDREW
Last Name:DIETELS
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 1:75 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-3333
Mailing Address - Country:US
Mailing Address - Phone:540-427-0567
Mailing Address - Fax:540-427-4367
Practice Address - Street 1:1455 TOWNE SQUARE BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1612
Practice Address - Country:US
Practice Address - Phone:540-265-0595
Practice Address - Fax:540-265-0596
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA061800456152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA487193OtherNVA PROVIDER #
VA009230645Medicaid
VA224243OtherANTHEM PROVIDER #
VA5709659OtherAETNA PROVIDER #
VA410044577Medicare PIN
VA487193OtherNVA PROVIDER #
VA5709659OtherAETNA PROVIDER #
VA009230645Medicaid
VAU70104Medicare UPIN