Provider Demographics
NPI:1881757177
Name:DIEGEL, ROBERT E (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:DIEGEL
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 1:6372 GUILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1750
Mailing Address - Country:US
Mailing Address - Phone:317-255-3333
Mailing Address - Fax:
Practice Address - Street 1:6372 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1750
Practice Address - Country:US
Practice Address - Phone:317-255-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003625152W00000X
IN18003489A152WS0006X, 152WP0200X, 152W00000X
IN18003489B152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU57683Medicare UPIN