1235166737 NPI number — DR. DEANNA JO DIEBOLD M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235166737 NPI number — DR. DEANNA JO DIEBOLD M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DIEBOLD

Provider First Name:

DEANNA

Provider Middle Name:

JO

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1235166737

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/30/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3366 OAKDALE AVE N STE 401

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ROBBINSDALE

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55422-2986

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

763-520-2940

Provider Business Mailing Address Fax Number:

763-520-2943

Provider First Line Business Practice Location Address:

3366 OAKDALE AVE N STE 401

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ROBBINSDALE

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55422-2986

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

635-202-9407

Provider Business Practice Location Address Fax Number:

763-520-2943

Provider Enumeration Date:

06/28/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0200X , with the licence number:  37330 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RP1001X , with the licence number: 37330 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: 37330 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0598920 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 32297100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 114004 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 315812800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 510K9DI . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 04-07870 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP19625 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0147135 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
• Identifier: 887653 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 04-00123 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".