Provider Demographics
NPI:1003875147
Name:DIEHL, JASON RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RICHARD
Last Name:DIEHL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:1025 COLUMBIA CTR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2546
Practice Address - Country:US
Practice Address - Phone:618-281-8611
Practice Address - Fax:618-281-3927
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00397557OtherRAILROAD MEDICARE
ILU89866Medicare UPIN
MO026006438Medicare PIN
MOU89866Medicare UPIN
ILK36231Medicare PIN