Provider Demographics
NPI:1649207937
Name:DIESTEL, ECKHART (MD)
Entity type:Individual
Prefix:DR
First Name:ECKHART
Middle Name:
Last Name:DIESTEL
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 1:1505 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4719
Mailing Address - Country:US
Mailing Address - Phone:574-364-2875
Mailing Address - Fax:574-364-2784
Practice Address - Street 1:1855 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4845
Practice Address - Country:US
Practice Address - Phone:574-533-7476
Practice Address - Fax:574-533-7145
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI13525207RI0011X
IN01047079A207RI0011X, 207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000256560OtherBLUE CROSS
HI575508Medicaid
IN201207610Medicaid
IN852791OtherANTHEM
ARH73420Medicare UPIN
IN201207610Medicaid
HI0000256560OtherBLUE CROSS