MEDICARE: DR. EIKE B DIEBOLD PH.D.

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
1	103T00000X	Psychologist	PSY 10583	CA

General Provider Information

NPI Number	:	1780606681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EIKE B DIEBOLD PH.D.

Provider Business Mailing Address
First Line	:	2428 DWIGHT WAY
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-3503
Country	:	US
Telephone Number	:	510-843-1396
Fax Number	:	925-283-6185

Provider Business Practice Location Address
First Line	:	2428 DWIGHT WAY
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-3503
Country	:	US
Telephone Number	:	510-843-1396
Fax Number	:	925-284-5859

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	11/04/2010

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