Basic Information
Provider Information | |||||||||
NPI: | 1225422322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUVAL | ||||||||
FirstName: | DIELLE | ||||||||
MiddleName: | L MEYER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 PARK ST | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421011708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707833343 | ||||||||
FaxNumber: | 2707800476 | ||||||||
Practice Location | |||||||||
Address1: | 201 PARK ST | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | KY | ||||||||
PostalCode: | 421011708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707833343 | ||||||||
FaxNumber: | 2707800476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2015 | ||||||||
LastUpdateDate: | 09/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0116030227 | VA | N |   | Allopathic & Osteopathic Physicians | Urology |   | 390200000X | 0116030227 | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208800000X | 56041 | KY | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.