Provider Demographics
NPI:1225002165
Name:STULC, DIANA MINASIAN (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MINASIAN
Last Name:STULC
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 1:5410 MARYLAND WAY 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37072-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5658
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:615-377-5658
Practice Address - Fax:888-241-1404
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20783207Q00000X
KY36090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01139543Medicaid
KY64024268Medicaid
MS$$$$$$$$$OtherBCBS MS
KY0992312Medicare PIN
KY64024268Medicaid
MS302I087874Medicare PIN
KY0965601Medicare ID - Type UnspecifiedLINKED TO GROUP # 9656