Provider Demographics
NPI:1871659193
Name:DIEHL, JEFFERY C (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:C
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 1:2305 S 65 HWY
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-0250
Mailing Address - Country:US
Mailing Address - Phone:660-886-7431
Mailing Address - Fax:660-831-3347
Practice Address - Street 1:2305 S. 65 HWY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-0250
Practice Address - Country:US
Practice Address - Phone:660-886-7431
Practice Address - Fax:660-831-3347
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106033207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO244717104Medicaid
MOG16972Medicare UPIN
MO082050156Medicare ID - Type Unspecified
MOE75000002Medicare PIN
MOX43000005Medicare PIN