=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407867245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL JOHN DIETERICHS OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 02/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3701 EUBANK BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-298-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1606 JACK NICKLAUS DR
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-450-5343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 390
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------