Provider Demographics
NPI:1962533695
Name:DIECKHOFF, JAY WILLIAM (M D)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:WILLIAM
Last Name:DIECKHOFF
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6152
Mailing Address - Country:US
Mailing Address - Phone:217-223-4702
Mailing Address - Fax:217-223-6984
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-223-9945
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064968207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00115241OtherBLUE SHIELD
IL036064968Medicaid
IL110123OtherBLUE SHIELD
ILC-43635Medicare UPIN