Provider Demographics
NPI:1497753214
Name:DIESFELD, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:DIESFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 N FRANCISCO AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2743
Mailing Address - Country:US
Mailing Address - Phone:773-868-6824
Mailing Address - Fax:773-868-6828
Practice Address - Street 1:1044 N FRANCISCO AVE STE 404
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2743
Practice Address - Country:US
Practice Address - Phone:773-868-6824
Practice Address - Fax:773-868-6828
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2022-05-20
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL036086023208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605512OtherBLUE SHIELD OF ILLINOIS
IL036086023Medicaid
IL01605512OtherBLUE SHIELD OF ILLINOIS
IL036086023Medicaid