Provider Demographics
NPI:1457384760
Name:DIECIDUE, SALLY E (OD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:E
Last Name:DIECIDUE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-1423
Mailing Address - Country:US
Mailing Address - Phone:610-863-5899
Mailing Address - Fax:
Practice Address - Street 1:300 MCMICHAELS DR
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-9149
Practice Address - Country:US
Practice Address - Phone:570-421-2723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6730P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist