Healthcare Provider Details

I. General information

NPI: 1891148151
Provider Name (Legal Business Name): MACY DIELEMAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MACY FICKBOHM O.D.

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 STORY ST
BOONE IA
50036-2834
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5469
US

V. Phone/Fax

Practice location:
  • Phone: 515-432-2020
  • Fax: 515-432-8482
Mailing address:
  • Phone: 515-239-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number083098
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: