Provider Demographics
NPI:1295751428
Name:DIECKGRAEFE, BRIAN K (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:DIECKGRAEFE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8124
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-8200
Mailing Address - Fax:314-362-8230
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:8TH FLOOR SUITE C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-454-8200
Practice Address - Fax:314-362-8230
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR3M46207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206755415Medicaid
MO206755415Medicaid
IL$$$$$$$$$Medicaid
MO206755415Medicaid