1669470183 NPI number — DR. CHRIS E DEITRICK O.D.

Table of content: DR. CHRIS E DEITRICK O.D. (NPI 1669470183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669470183 NPI number — DR. CHRIS E DEITRICK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEITRICK
Provider First Name:
CHRIS
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669470183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1460
Provider Second Line Business Mailing Address:
101 CASE COMMONS DRIVE
Provider Business Mailing Address City Name:
MOUNTAIN VIEW
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72560-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-269-3610
Provider Business Mailing Address Fax Number:
870-269-5086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CASE COMMONS DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN VIEW
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-269-3610
Provider Business Practice Location Address Fax Number:
870-269-5086
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  2516 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2516 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431988740 . This is a "TAX ID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 145299722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4709560001 . This is a "MEDICARE DMEPOS ID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 19930000041 . This is a "QUALCHOICE ID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 410049416 . This is a "MEDICARE RR ID#" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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