Provider Demographics
NPI:1083766935
Name:DIECKMAN, TIMOTHY JUDE (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JUDE
Last Name:DIECKMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:PINE BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08741
Mailing Address - Country:US
Mailing Address - Phone:732-341-6555
Mailing Address - Fax:732-557-6369
Practice Address - Street 1:631 JAMAICA BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757-4000
Practice Address - Country:US
Practice Address - Phone:732-341-6555
Practice Address - Fax:732-557-6369
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38NJMC0047700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U59270Medicare UPIN
NJ804141Medicare ID - Type Unspecified