MEDICARE: MICHAEL J DEIBOLDT OD

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	0681800575	VA

General Provider Information

NPI Number	:	1083705826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J DEIBOLDT OD

Provider Business Mailing Address
First Line	:	420 W JUBAL EARLY DR STE 200
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22601-6435
Country	:	US
Telephone Number	:	540-662-2700
Fax Number	:	540-662-8801

Provider Business Practice Location Address
First Line	:	420 W JUBAL EARLY DR STE 200
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22601-6435
Country	:	US
Telephone Number	:	540-662-2700
Fax Number	:	540-662-8801

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	11/10/2022

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