Provider Demographics
NPI:1114993516
Name:DIEBOLD, KURT A (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:A
Last Name:DIEBOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WHITNEY TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-2136
Mailing Address - Country:US
Mailing Address - Phone:774-270-2799
Mailing Address - Fax:
Practice Address - Street 1:235 WOODLAND N
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-1414
Practice Address - Country:US
Practice Address - Phone:781-715-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213606207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0172863Medicaid
MA110005966AMedicaid
MA0172863Medicaid
NY02742547Medicaid
MA0172863Medicaid