=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902872971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAKOW DIENER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 07/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 BROOK RD
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03574-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-616-9916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 BROOK RD
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03574-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-616-9916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 12255
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------