Individual
DR. JACK DIEP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1791 MESQUITE AVE, LAKE HAVASU CITY, AZ 86403-5648
(928) 505-5555
(928) 505-2877
Mailing address
25 RIVIERA BLVD, LAKE HAVASU CITY, AZ 86403-5694
(928) 505-5555
(928) 505-2877
Taxonomy
Speciality
Code
Description
License number
State
207LP2900X
Pain Medicine (Anesthesiology) Physician
55528
AZ
208VP0000X
Pain Medicine Physician
55528
AZ
208VP0014X
Interventional Pain Medicine Physician
Primary
55528
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
369607
—
AZ
Enumeration date
09/20/2013
Last updated
09/27/2022
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