Basic Information
| Provider Information | |||||||||
| NPI: | 1144215823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAGLE | ||||||||
| FirstName: | DIEDRE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 15215 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3527990115 | ||||||||
| Practice Location | |||||||||
| Address1: | 4270 LAKE IN THE WOODS DR | ||||||||
| Address2: | |||||||||
| City: | WEEKI WACHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346072501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525977249 | ||||||||
| FaxNumber: | 3525979523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | ME 88175 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 271034000 | 05 | FL | MEDICAID | P01125564 | 01 | FL | RR MCR | OTHER | 37307 | 01 | FL | BCBS | OTHER | U1375S | 01 | FL | MEDICARE TYPE - UNSPECIFIED | OTHER |