Provider Demographics
NPI:1700803897
Name:GARY LEE DIETTERICK
Entity Type:Organization
Organization Name:GARY LEE DIETTERICK
Other - Org Name:PALMER FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIETTERICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-258-2442
Mailing Address - Street 1:21 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2664
Mailing Address - Country:US
Mailing Address - Phone:610-258-2442
Mailing Address - Fax:610-258-7961
Practice Address - Street 1:21 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2664
Practice Address - Country:US
Practice Address - Phone:610-258-2442
Practice Address - Fax:610-258-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADD4313OtherPALMETTO GBA RAILROAD MED
PA02669200OtherCAPITAL BLUE CROSS
PA3803518OtherAETNA
PA624066OtherHIGHMARK BLUE SHIELD
PA02669200OtherKEYSTONE
PA0255130001Medicare NSC
PA02669200OtherKEYSTONE
PADD4313OtherPALMETTO GBA RAILROAD MED