Provider Demographics
NPI:1346534146
Name:TAMBOLI, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:TAMBOLI
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 1:16315 N MAY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8892
Mailing Address - Country:US
Mailing Address - Phone:405-521-0041
Mailing Address - Fax:405-521-1689
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:405-521-1689
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3979207W00000X
IL125061038207W00000X
OK32188207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200653870AMedicaid
OK200653870AMedicaid