Provider Demographics
NPI:1114393626
Name:CARL F DIENER MD PC
Entity Type:Organization
Organization Name:CARL F DIENER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-6267
Mailing Address - Street 1:5375 E ERICKSON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2838
Mailing Address - Country:US
Mailing Address - Phone:520-327-6267
Mailing Address - Fax:520-321-0086
Practice Address - Street 1:5375 E ERICKSON DR STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2838
Practice Address - Country:US
Practice Address - Phone:520-327-6267
Practice Address - Fax:520-321-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5462261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ230730Medicaid
AZ230730Medicaid