Provider Demographics
NPI:1194915272
Name:DIEP, IRENE (OD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:DIEP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 S BROADWAY STE F
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4034
Mailing Address - Country:US
Mailing Address - Phone:213-749-9966
Mailing Address - Fax:213-277-5865
Practice Address - Street 1:1001 S BROADWAY STE F
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:213-749-9966
Practice Address - Fax:213-277-5865
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13166T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015755H24Medicare PIN