Provider Demographics
NPI:1225128093
Name:DIEHL, DOUGLAS KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KENT
Last Name:DIEHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-779-1082
Mailing Address - Fax:541-608-2888
Practice Address - Street 1:1025 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7689
Practice Address - Country:US
Practice Address - Phone:541-779-1282
Practice Address - Fax:541-608-2888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23570174400000X, 207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORB52434Medicare UPIN