Provider Demographics
NPI:1093799587
Name:MAENNLE, DIANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:MAENNLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-678-1861
Mailing Address - Fax:
Practice Address - Street 1:7733 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3707
Practice Address - Country:US
Practice Address - Phone:313-499-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055489207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE50456Medicare UPIN
220010629Medicare PIN
MI26256012Medicare ID - Type Unspecified
MI0H26256012Medicare PIN
MI26256012Medicare PIN