MEDICARE: JEANNENE L DIETER 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	OP0002256	FL

General Provider Information

NPI Number	:	1417955451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNENE L DIETER O.D.

Provider Business Mailing Address
First Line	:	8312 US HIGHWAY 301 N STE 105
Second Line	:
City	:	PARRISH
State	:	FL
Zip	:	34219-8725
Country	:	US
Telephone Number	:	941-776-0577
Fax Number	:	941-845-0162

Provider Business Practice Location Address
First Line	:	8312 US HIGHWAY 301 N STE 105
Second Line	:
City	:	PARRISH
State	:	FL
Zip	:	34219-8725
Country	:	US
Telephone Number	:	941-776-5770
Fax Number	:	941-845-0162

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	03/16/2023

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