Provider Demographics
NPI:1952664989
Name:JAIYEOLA, DIANA MARIE
Entity Type:Individual
Prefix:
First Name:DIANA MARIE
Middle Name:
Last Name:JAIYEOLA
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 1:701 OSTRUM ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1152
Mailing Address - Country:US
Mailing Address - Phone:484-526-6545
Mailing Address - Fax:484-526-6546
Practice Address - Street 1:701 OSTRUM ST STE 201
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1152
Practice Address - Country:US
Practice Address - Phone:484-526-6545
Practice Address - Fax:484-526-6546
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061984208600000X
PAMD462150207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208600000XAllopathic & Osteopathic PhysiciansSurgery