Provider Demographics
NPI:1326138199
Name:DIEHL, LISA A
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DIEHL
Suffix:
Gender:F
Credentials:
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 1536
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1536
Mailing Address - Country:US
Mailing Address - Phone:985-635-6943
Mailing Address - Fax:985-635-6948
Practice Address - Street 1:8595 UNITED PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2251
Practice Address - Country:US
Practice Address - Phone:985-635-6943
Practice Address - Fax:985-635-6948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10808R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490946Medicaid
LA1490946Medicaid
LA5A116Medicare ID - Type Unspecified