Provider Demographics
NPI:1326155532
Name:STAUDINGER, DIANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:STAUDINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LA VERNE
Other - Last Name:STAUDINGER
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3509 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-686-5731
Mailing Address - Fax:920-686-5726
Practice Address - Street 1:3509 DEWEY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-686-5731
Practice Address - Fax:920-686-5726
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32004900Medicaid
BS3218004OtherDEA NUMBER
381080025Medicare ID - Type UnspecifiedMEDICARE PROVIDER
F75134Medicare UPIN