Provider Demographics
NPI:1154380673
Name:DIEDRICH, DANIEL D (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:D
Last Name:DIEDRICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-0168
Mailing Address - Country:US
Mailing Address - Phone:765-664-6148
Mailing Address - Fax:765-664-9782
Practice Address - Street 1:1400 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952
Practice Address - Country:US
Practice Address - Phone:765-664-6148
Practice Address - Fax:765-664-9782
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002338A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1000094740Medicaid
IN160450CMedicare PIN
IN410039138Medicare PIN
INT30510Medicare UPIN
IN410043098Medicare PIN
IN811310BMedicare PIN
IN1000094740Medicaid
IN410037500Medicare PIN
IN410035888Medicare PIN
IN084200BMedicare PIN
IN452570016Medicare PIN