Provider Demographics
NPI:1093807786
Name:PALKERT, DIANE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:PALKERT
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 1:318 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1691
Mailing Address - Country:US
Mailing Address - Phone:218-546-8375
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:318 EAST MAIN STREET
Practice Address - Street 2:CENTRAL LAKES MEDICAL CLINIC PA
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1691
Practice Address - Country:US
Practice Address - Phone:218-546-8375
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43000207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H27221Medicare UPIN