Provider Demographics
NPI:1235237074
Name:HENTZ, DIANE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:HENTZ
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 1:5750 FALLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7147
Mailing Address - Country:US
Mailing Address - Phone:260-436-8000
Mailing Address - Fax:260-432-5587
Practice Address - Street 1:5750 FALLS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7147
Practice Address - Country:US
Practice Address - Phone:260-436-8000
Practice Address - Fax:260-432-5587
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038843A207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00074720OtherMEDICARE RAILROAD
IN01038843BOtherCSR LICENSE NUMBER
1390OtherPHP
000000308077OtherBCBS
4045038OtherAETNA
IN100359250Medicaid
IN100359250Medicaid
4045038OtherAETNA
000000308077OtherBCBS