Provider Demographics
NPI:1942226865
Name:DIETRICH, ROBERT CRAIG (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CRAIG
Last Name:DIETRICH
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 1:515 NIOBRARA AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-3421
Mailing Address - Country:US
Mailing Address - Phone:308-762-3124
Mailing Address - Fax:308-762-7326
Practice Address - Street 1:515 NIOBRARA AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3421
Practice Address - Country:US
Practice Address - Phone:308-762-3124
Practice Address - Fax:308-762-7326
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE817152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06778OtherBLUE CROSS BLUE SHIELD
NEP00078205Medicare PIN
NE277013Medicare PIN
NET83317Medicare UPIN