Healthcare Provider Details

I. General information

NPI: 1982809273
Provider Name (Legal Business Name): JOHN W DIEHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HILL ST
BUCYRUS OH
44820-1566
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 567-307-7595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDR.0068644
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35089810
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: