1215030366 NPI number — DR. DIANNE MARTIN MD

Table of content: DR. DIANNE MARTIN MD (NPI 1215030366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215030366 NPI number — DR. DIANNE MARTIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
DIANNE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
DIANNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215030366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5670 CAITO DR
Provider Second Line Business Mailing Address:
SUITE #125 BUILDING # 5
Provider Business Mailing Address City Name:
INDPLS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46226-1364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-541-9159
Provider Business Mailing Address Fax Number:
317-541-9179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5670 CAITO DR
Provider Second Line Business Practice Location Address:
SUITE #125 BUILDING # 5
Provider Business Practice Location Address City Name:
INDPLS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46226-1364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-541-9159
Provider Business Practice Location Address Fax Number:
317-541-9179
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  01029502 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 01029502A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100235680 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: I010268 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10023568019 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000079659 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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