Provider Demographics
NPI:1992735807
Name:DEIBOLDT, DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DEIBOLDT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10720 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-2138
Mailing Address - Country:US
Mailing Address - Phone:301-937-5666
Mailing Address - Fax:301-937-0453
Practice Address - Street 1:10720 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-2138
Practice Address - Country:US
Practice Address - Phone:301-937-5666
Practice Address - Fax:301-937-0453
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01308213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9022007 00Medicaid
MD00A838J95Medicare PIN
MD9022007 00Medicaid
MD0422880001Medicare NSC