Individual
DR. CHRIS E DEITRICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
101 CASE COMMONS DR., MOUNTAIN VIEW, AR 72560
(870) 269-3610
(870) 269-5086
Mailing address
PO BOX 1460, 101 CASE COMMONS DRIVE, MOUNTAIN VIEW, AR 72560-1460
(870) 269-3610
(870) 269-5086
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2516
AR
152WC0802X
Corneal and Contact Management Optometrist
2516
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
145299722
—
AR
01
—
19930000041
QUALCHOICE ID #
AR
01
—
410049416
MEDICARE RR ID#
AR
01
—
431988740
TAX ID #
AR
01
—
4709560001
MEDICARE DMEPOS ID #
AR
Enumeration date
07/08/2005
Last updated
08/14/2023
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