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NPI Code Detail

MEDICARE: DR. SHANE DENNIS DIECKMAN D.O.

MEDICARE: DR. SHANE DENNIS DIECKMAN D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology PhysicianDR.0055905CO
22085R0202XDiagnostic Radiology Physician305NE

General Provider Information

NPI Number : 1487647368
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHANE DENNIS DIECKMAN D.O.
Provider Business Mailing Address
First Line : 4102 PINION DR
Second Line :
City : USAF ACADEMY
State : CO
Zip : 80840-2502
Country : US
Telephone Number : 719-333-5115
Fax Number :
Provider Business Practice Location Address
First Line : 2501 CAPEHART RD
Second Line :
City : OFFUTT AFB
State : NE
Zip : 68113-1043
Country : US
Telephone Number : 402-294-2448
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2005
Last Update Date : 10/15/2019

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