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NPI Code Detail

MEDICARE: DR. SALLY E DIECIDUE O.D.

MEDICARE: DR. SALLY E DIECIDUE 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
1152W00000XOptometrist6730PPA

General Provider Information

NPI Number : 1457384760
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SALLY E DIECIDUE O.D.
Provider Business Mailing Address
First Line : 37 S BROADWAY
Second Line :
City : WIND GAP
State : PA
Zip : 18091-1423
Country : US
Telephone Number : 610-863-5899
Fax Number :
Provider Business Practice Location Address
First Line : 300 MCMICHAELS DR
Second Line :
City : STROUDSBURG
State : PA
Zip : 18360-9149
Country : US
Telephone Number : 570-421-2723
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/09/2006
Last Update Date : 07/08/2007

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Directions to “ DR. SALLY E DIECIDUE O.D.” Practice Location

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