Provider Demographics
NPI:1114211422
Name:DIERFELDT, DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DIERFELDT
Suffix:
Gender:M
Credentials:DO
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-589-6788
Mailing Address - Fax:502-589-5093
Practice Address - Street 1:401 E CHESTNUT ST UNIT 310
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5703
Practice Address - Country:US
Practice Address - Phone:502-589-6788
Practice Address - Fax:502-589-5093
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04544207Q00000X, 207QH0002X
IL125.059121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100607570Medicaid