Provider Demographics
NPI:1700933215
Name:DEITRICK, JUDY L (OPTICIAN)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:L
Last Name:DEITRICK
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:MS
Other - First Name:JUDY
Other - Middle Name:L
Other - Last Name:DEITRICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:2631-3 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4693
Mailing Address - Country:US
Mailing Address - Phone:904-765-3611
Mailing Address - Fax:904-765-4256
Practice Address - Street 1:2631 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4656
Practice Address - Country:US
Practice Address - Phone:904-765-3611
Practice Address - Fax:904-765-4256
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2024156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0548620001Medicare NSC