Healthcare Provider Details

I. General information

NPI: 1932455136
Provider Name (Legal Business Name): DR. MARK EDWARD DIEBEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 1001
JACKSONVILLE FL
32207-8337
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-0033
  • Fax: 904-398-6774
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-396-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME132260
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: