Provider Demographics
NPI:1972229540
Name:DIEBOLD, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DIEBOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WHITNEY TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-2136
Mailing Address - Country:US
Mailing Address - Phone:774-270-6661
Mailing Address - Fax:
Practice Address - Street 1:412 SEYMOUR RD APT 4
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-1588
Practice Address - Country:US
Practice Address - Phone:774-270-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program