MEDICARE: TREV DIDELOT 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	18004509A	IN

General Provider Information

NPI Number	:	1629811377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREV DIDELOT OD

Provider Business Mailing Address
First Line	:	1028 SCHROEDER AVE
Second Line	:
City	:	JASPER
State	:	IN
Zip	:	47546-3743
Country	:	US
Telephone Number	:	812-639-8988
Fax Number	:

Provider Business Practice Location Address
First Line	:	8010 OAK PARK RD NE
Second Line	:
City	:	NEW SALISBURY
State	:	IN
Zip	:	47161-8401
Country	:	US
Telephone Number	:	812-366-3147
Fax Number	:

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

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/18/2024

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