Provider Demographics
NPI:1285630996
Name:DIECIDUE, ANTHONY S (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:S
Last Name:DIECIDUE
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 1:208 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2502
Mailing Address - Country:US
Mailing Address - Phone:570-476-1114
Mailing Address - Fax:570-476-9520
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2502
Practice Address - Country:US
Practice Address - Phone:570-476-1114
Practice Address - Fax:570-476-9520
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000110152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA084299OtherBCBS
PA084299OtherBCBS
PA084299P7VMedicare ID - Type UnspecifiedMEDICARE