Provider Demographics
NPI:1922097179
Name:FELLNER, DIETRICH ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:DIETRICH
Middle Name:ALBERT
Last Name:FELLNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:813 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6004
Mailing Address - Country:US
Mailing Address - Phone:757-490-9091
Mailing Address - Fax:757-490-3250
Practice Address - Street 1:813 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6004
Practice Address - Country:US
Practice Address - Phone:757-490-9091
Practice Address - Fax:757-490-3250
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101232452207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110252OtherANTHEM BLUE CROSS
VA541206650OtherTRICARE
VA010030013Medicaid
VA110252OtherANTHEM BLUE CROSS
VA541206650OtherTRICARE
VA0761520001Medicare NSC