Provider Demographics
NPI:1235166737
Name:DIEBOLD, DEANNA JO (MD)
Entity Type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:JO
Last Name:DIEBOLD
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 1:3366 OAKDALE AVE N STE 401
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2986
Mailing Address - Country:US
Mailing Address - Phone:763-520-2940
Mailing Address - Fax:763-520-2943
Practice Address - Street 1:3366 OAKDALE AVE N STE 401
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2986
Practice Address - Country:US
Practice Address - Phone:635-202-9407
Practice Address - Fax:763-520-2943
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37330207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0598920Medicaid
WI32297100Medicaid
MN114004OtherUCARE
MN315812800Medicaid
MN510K9DIOtherBCBS
MN04-07870OtherMEDICA CHOICE
MNHP19625OtherHEALTHPARTNERS
MT0147135Medicaid
MN887653OtherARAZ
MN04-00123OtherMEDICA PRIMARY
MN04-00123OtherMEDICA PRIMARY