Healthcare Provider Details

I. General information

NPI: 1235166737
Provider Name (Legal Business Name): DEANNA JO DIEBOLD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N STE 401
ROBBINSDALE MN
55422-2986
US

IV. Provider business mailing address

3366 OAKDALE AVE N STE 401
ROBBINSDALE MN
55422-2986
US

V. Phone/Fax

Practice location:
  • Phone: 635-202-9407
  • Fax: 763-520-2943
Mailing address:
  • Phone: 763-520-2940
  • Fax: 763-520-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number37330
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number37330
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37330
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: