Provider Demographics
NPI:1447249214
Name:DIEHL, GREGORY JOHN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:DIEHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 10
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3184
Mailing Address - Country:US
Mailing Address - Phone:631-476-7300
Mailing Address - Fax:631-476-7304
Practice Address - Street 1:1500 ROUTE 112 BLDG # 10
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-476-7300
Practice Address - Fax:631-476-7304
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1902162208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
89K831Medicare ID - Type Unspecified
E87758Medicare UPIN