Provider Demographics
NPI:1962513937
Name:ANTHONY S. DIECIDUE, P.C.
Entity type:Organization
Organization Name:ANTHONY S. DIECIDUE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIECIDUE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-476-1114
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:
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA053064Medicare ID - Type Unspecified
PA0670250001Medicare NSC