Provider Demographics
NPI:1215030366
Name:MARTIN, DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5670 CAITO DR
Mailing Address - Street 2:SUITE #125 BUILDING # 5
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-1364
Mailing Address - Country:US
Mailing Address - Phone:317-541-9159
Mailing Address - Fax:317-541-9179
Practice Address - Street 1:5670 CAITO DR
Practice Address - Street 2:SUITE #125 BUILDING # 5
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46226-1364
Practice Address - Country:US
Practice Address - Phone:317-541-9159
Practice Address - Fax:317-541-9179
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010295022084P0800X
IN01029502A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100235680Medicaid
I010268OtherTRICARE
IN10023568019Medicaid
000000079659OtherBCBS
D70780Medicare UPIN
IN10023568019Medicaid
I010268OtherTRICARE
IN100235680Medicaid