Provider Demographics
NPI:1770530941
Name:DIEKHOFF, EDWARD JOHN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
Last Name:DIEKHOFF
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E COUNTY LINE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-865-8000
Practice Address - Fax:317-865-8012
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039037A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000351070OtherANTHEM ID
INP00171329OtherMEDICARE RAILROAD ID
IN200019310Medicaid
IN4218208OtherAETNA ELIGIBILITY ID
IN000000001722OtherMDWISE/PRO HEALTH ID
IN10813894OtherCAQH ID
INP01157057OtherRR MEDICARE PTAN
IN200019310Medicaid
IN266180007Medicare PIN
IN266180007Medicare PIN