Provider Demographics
NPI:1104801489
Name:DIEKEMA, DANIEL J (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:DIEKEMA
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 1:41 DONALD B DEAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3252
Mailing Address - Country:US
Mailing Address - Phone:207-661-7901
Mailing Address - Fax:
Practice Address - Street 1:41 DONALD B DEAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3252
Practice Address - Country:US
Practice Address - Phone:207-661-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28731207R00000X, 207RI0200X, 207ZP0102X
MEMD14027207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA47989OtherWELLMARK BCBS
IA0098376Medicaid
IA440002892Medicare PIN
IA47989OtherWELLMARK BCBS
F57674Medicare UPIN