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General NPI Number Information
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NPI Number | 1902855414
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Entity Type | Individual
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Provider Name | GUY ANDREW DIETELS O.D.
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Gender | Male
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Dates
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Enumeration Date | 05/10/2006
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Last Update Date | 07/18/2008
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Provider Practice Location Address
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Address Line | 1455 TOWNE SQUARE BLVD NW
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City | ROANOKE
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State | VA
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Zip | 24012-1612
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Country | US
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Telephone | 540-265-0595
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Fax | 540-265-0596
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Provider Business Mailing Address
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Address Line | 75 BITTERSWEET LN
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City | HARDY
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State | VA
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Zip | 24101-3333
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Country | US
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Telephone | 540-427-0567
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Fax | 540-427-4367
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 061800456
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License Number State | VA
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