Provider Demographics
NPI:1073590667
Name:PUGH, DIANE L (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:PUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:1215 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4702
Practice Address - Country:US
Practice Address - Phone:772-468-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS0006117OtherMEDICAL LICENSE
FL80576OtherBLUE CROSS BLUE SHIELD
FLP01744365OtherRR MEDICARE
FL80576OtherBLUE CROSS BLUE SHIELD
FLF15281Medicare UPIN
FLP01744365OtherRR MEDICARE