Provider Demographics
NPI:1114099983
Name:DIATA, DOUGLAS T (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:T
Last Name:DIATA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MICHIGAN AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3609
Mailing Address - Country:US
Mailing Address - Phone:269-968-9355
Mailing Address - Fax:269-968-9366
Practice Address - Street 1:2 MICHIGAN AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3609
Practice Address - Country:US
Practice Address - Phone:269-968-9355
Practice Address - Fax:269-968-9366
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI95-0-A3-5020-0OtherBLUE CROSS BLUE SHIELD
MION48090Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER