Provider Demographics
NPI:1144214560
Name:DIENER, DANIEL A (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:DIENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5232
Mailing Address - Country:US
Mailing Address - Phone:574-535-9100
Mailing Address - Fax:574-535-1020
Practice Address - Street 1:2006 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5232
Practice Address - Country:US
Practice Address - Phone:574-535-9100
Practice Address - Fax:574-535-1020
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052698A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200269110Medicaid
164560GMedicare ID - Type Unspecified
H19254Medicare UPIN