MEDICARE: DR. ANTHONY S DIECIDUE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG000110	PA
2	152WC0802X	Corneal and Contact Management Optometrist	OEG000110	PA
3	152WL0500X	Low Vision Rehabilitation Optometrist	OEG000110	PA
4	152WP0200X	Pediatric Optometrist	OEG000110	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	084299	OTHER	PA	BCBS

General Provider Information

NPI Number	:	1285630996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY S DIECIDUE O.D.

Provider Business Mailing Address
First Line	:	208 MAIN ST
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-2502
Country	:	US
Telephone Number	:	570-476-1114
Fax Number	:	570-476-9520

Provider Business Practice Location Address
First Line	:	208 MAIN ST
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-2502
Country	:	US
Telephone Number	:	570-476-1114
Fax Number	:	570-476-9520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	09/09/2011

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