Provider Demographics
NPI:1134276355
Name:DIETZ, GARY L (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:DIETZ
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 1:1011 LENORA CT
Mailing Address - Street 2:#111
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6800
Mailing Address - Country:US
Mailing Address - Phone:360-305-0402
Mailing Address - Fax:
Practice Address - Street 1:1303 CORNWALL AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4716
Practice Address - Country:US
Practice Address - Phone:360-647-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA3717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist