Provider Demographics
NPI:1629811377
Name:DIDELOT, TREV (OD)
Entity type:Individual
Prefix:
First Name:TREV
Middle Name:
Last Name:DIDELOT
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 1:1028 SCHROEDER AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-3743
Mailing Address - Country:US
Mailing Address - Phone:812-639-8988
Mailing Address - Fax:
Practice Address - Street 1:8010 OAK PARK RD NE
Practice Address - Street 2:
Practice Address - City:NEW SALISBURY
Practice Address - State:IN
Practice Address - Zip Code:47161-8401
Practice Address - Country:US
Practice Address - Phone:812-366-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004509A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty