Provider Demographics
NPI:1467460535
Name:DIAMOND, MICHAEL S (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:DIAMOND
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 1:6510 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6714
Mailing Address - Country:US
Mailing Address - Phone:315-865-4299
Mailing Address - Fax:
Practice Address - Street 1:25737 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3221
Practice Address - Country:US
Practice Address - Phone:315-629-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV3148NYS152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU28494Medicare UPIN