Provider Demographics
NPI:1417182619
Name:GASTON I. S. DIALLO, MD, PA
Entity Type:Organization
Organization Name:GASTON I. S. DIALLO, MD, PA
Other - Org Name:GASTON I. SALIOU-DIALLO, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GASTROENTEROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GASTON
Authorized Official - Middle Name:I S
Authorized Official - Last Name:DIALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-682-9030
Mailing Address - Street 1:113 DELAWARE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-2822
Mailing Address - Country:US
Mailing Address - Phone:913-682-9030
Mailing Address - Fax:
Practice Address - Street 1:113 DELAWARE ST
Practice Address - Street 2:SUITE E
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-2822
Practice Address - Country:US
Practice Address - Phone:913-682-9030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-16539282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2021825601Medicaid
KS100084540AOtherKS MEDICAL ASSISTANCE PROGRAM
KS100084540AOtherKS MEDICAL ASSISTANCE PROGRAM
001858Medicare PIN