Provider Demographics
NPI:1265412639
Name:DEWITT, DIANE C (OD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:DEWITT
Suffix:
Gender:F
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:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-0700
Mailing Address - Country:US
Mailing Address - Phone:575-763-5522
Mailing Address - Fax:575-763-4722
Practice Address - Street 1:1217 PILE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5944
Practice Address - Country:US
Practice Address - Phone:575-763-5522
Practice Address - Fax:575-763-4722
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP1167Medicaid
NMNM00P427OtherBCBS
NMP1167Medicaid
NM0173070001Medicare NSC
NMU02943Medicare UPIN