Healthcare Provider Details

I. General information

NPI: 1649207937
Provider Name (Legal Business Name): ECKHART DIESTEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 S MAIN ST STE A
GOSHEN IN
46526-4845
US

IV. Provider business mailing address

1505 S MAIN ST
GOSHEN IN
46526-4719
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-7476
  • Fax: 574-533-7145
Mailing address:
  • Phone: 574-364-2875
  • Fax: 574-364-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13525
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number01047079A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01047079A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01047079A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: