Basic Information
| Provider Information | |||||||||
| NPI: | 1104801489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEKEMA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 DONALD B DEAN DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076617901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41 DONALD B DEAN DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076617901 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 28731 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 28731 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207ZP0102X | 28731 | IA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207RI0200X | MD14027 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 47989 | 01 | IA | WELLMARK BCBS | OTHER | 0098376 | 05 | IA | MEDICAID |