Provider Demographics
NPI:1376580316
Name:BROGAN, DIANNA W (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:W
Last Name:BROGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:
Other - Last Name:WROBLEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1101 E GLENDALE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:219-462-0555
Mailing Address - Fax:219-548-3681
Practice Address - Street 1:1101 E GLENDALE BLVD
Practice Address - Street 2:STE 101
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-462-0555
Practice Address - Fax:219-548-3681
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01045568208000000X
ILIL036093483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000187216OtherANTHEM
IN200096250Medicare ID - Type Unspecified
H80081Medicare UPIN