Healthcare Provider Details

I. General information

NPI: 1952664989
Provider Name (Legal Business Name): DIANA MARIE JAIYEOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 OSTRUM ST STE 201
FOUNTAIN HILL PA
18015-1152
US

IV. Provider business mailing address

701 OSTRUM ST STE 201
FOUNTAIN HILL PA
18015-1152
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-6545
  • Fax: 484-526-6546
Mailing address:
  • Phone: 484-526-6545
  • Fax: 484-526-6546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD462150
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125061984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: