Provider Demographics
NPI:1932644960
Name:ANTHONY S. DIECIDUE P.C.
Entity Type:Organization
Organization Name:ANTHONY S. DIECIDUE P.C.
Other - Org Name:EYE ASSOCIATES OF PAUPACK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GLASNER
Authorized Official - Suffix:IV
Authorized Official - Credentials:OD
Authorized Official - Phone:570-226-2400
Mailing Address - Street 1:208 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2575
Mailing Address - Country:US
Mailing Address - Phone:570-226-2400
Mailing Address - Fax:570-226-2401
Practice Address - Street 1:2571 RTE 6
Practice Address - Street 2:SUITE 1
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428
Practice Address - Country:US
Practice Address - Phone:570-226-2400
Practice Address - Fax:570-226-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007411850003Medicaid
PA1007411850003Medicaid
PA0670250001Medicare NSC