Provider Demographics
NPI:1053607515
Name:DIEHL, CHRISTOPHER S (OD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:DIEHL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1140
Mailing Address - Country:US
Mailing Address - Phone:712-239-3937
Mailing Address - Fax:
Practice Address - Street 1:4405 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1140
Practice Address - Country:US
Practice Address - Phone:712-239-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1053607515Medicaid
IA1053607515Medicare PIN