Healthcare Provider Details

I. General information

NPI: 1871659193
Provider Name (Legal Business Name): JEFFERY C DIEHL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 S. 65 HWY
MARSHALL MO
65340-0250
US

IV. Provider business mailing address

2305 S 65 HWY
MARSHALL MO
65340-0250
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-7431
  • Fax: 660-831-3347
Mailing address:
  • Phone: 660-886-7431
  • Fax: 660-831-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number106033
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106033
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: