MEDICARE: DR. DIETRICH ALBERT FELLNER M.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
1	207W00000X	Ophthalmology Physician	0101232452	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110252	OTHER	VA	ANTHEM BLUE CROSS
2	541206650	OTHER	VA	TRICARE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922097179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIETRICH ALBERT FELLNER M.D.

Provider Business Mailing Address
First Line	:	813 INDEPENDENCE BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6004
Country	:	US
Telephone Number	:	757-490-9091
Fax Number	:	757-490-3250

Provider Business Practice Location Address
First Line	:	813 INDEPENDENCE BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6004
Country	:	US
Telephone Number	:	757-490-9091
Fax Number	:	757-490-3250

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	05/09/2013

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