Provider Demographics
NPI:1144215823
Name:CAGLE, DIEDRE T (MD)
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:T
Last Name:CAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15215 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6072
Mailing Address - Country:US
Mailing Address - Phone:352-799-0046
Mailing Address - Fax:352-799-0115
Practice Address - Street 1:4270 LAKE IN THE WOODS DR
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34607-2501
Practice Address - Country:US
Practice Address - Phone:352-597-7249
Practice Address - Fax:352-597-9523
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88175207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271034000Medicaid
FLP01125564OtherRR MCR
FL37307OtherBCBS
FLU1375SOtherMEDICARE TYPE - UNSPECIFIED
B59391Medicare UPIN
FL271034000Medicaid
FL37307OtherBCBS
FLP01125564OtherRR MCR
FLU41375XMedicare Oscar/Certification