1417182619 NPI number — GASTON I. S. DIALLO, MD, PA

Table of content: (NPI 1417182619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417182619 NPI number — GASTON I. S. DIALLO, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTON I. S. DIALLO, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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 Information

NPI Number:
1417182619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 DELAWARE ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
LEAVENWORTH
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66048-2822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-682-9030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 DELAWARE ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-2822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-682-9030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DIALLO
Authorized Official First Name:
GASTON
Authorized Official Middle Name:
I. S.
Authorized Official Title or Position:
GASTROENTEROLOGIST
Authorized Official Telephone Number:
913-682-9030

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  04-16539 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2021825601 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100084540A . This is a "KS MEDICAL ASSISTANCE PROGRAM" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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