Provider Demographics
NPI:1134117385
Name:DODGEN, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DODGEN
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 1:330 BISHOP BLVD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347-3618
Mailing Address - Country:US
Mailing Address - Phone:850-584-3278
Mailing Address - Fax:850-584-8171
Practice Address - Street 1:315 E ASH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2029
Practice Address - Country:US
Practice Address - Phone:850-584-3278
Practice Address - Fax:850-584-8171
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99971261QP2300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279528100Medicaid
FLAG1272Medicare PIN
F25674Medicare UPIN
FL279528100Medicaid
FLAG1272Medicare PIN