Provider Information for 1316942378
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KEVIN O DIECKHAUS MD
Sex: Male
NPI: 1316942378
Last Updated: 2022-09-20
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1316942378 | ||||||||||||||
| Enumeration Date | 2005-06-16 | ||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||
| Sole Proprietor | NO | ||||||||||||||
| Status | Active | ||||||||||||||
| Mailing Address | 263 FARMINGTON AVE PROVIDER ENROLLMENT FARMINGTON, CT 06030-2212 United States Phone: 860-679-7503 | Fax:860-679-1610 | ||||||||||||||
| Primary Practice Address | 263 FARMINGTON AVE FARMINGTON, CT 06030-0001 United States Phone: 860-679-4225 | Fax:860-679-1217 | ||||||||||||||
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