Provider Demographics
NPI:1164057543
Name:DIANA TAMBOLI MD LLC
Entity Type:Organization
Organization Name:DIANA TAMBOLI MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMBOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-300-3857
Mailing Address - Street 1:7605 NW 133RD PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-4451
Mailing Address - Country:US
Mailing Address - Phone:405-408-4064
Mailing Address - Fax:405-936-0561
Practice Address - Street 1:16315 N MAY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8892
Practice Address - Country:US
Practice Address - Phone:405-521-0041
Practice Address - Fax:405-936-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-06
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200653870AMedicaid