Provider Demographics
NPI:1407887763
Name:LILJEGREN, DIANE L (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:LILJEGREN
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 1:3100 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5746
Mailing Address - Country:US
Mailing Address - Phone:907-228-8300
Mailing Address - Fax:907-228-8518
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-8140
Practice Address - Fax:907-228-8440
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2793207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD27931Medicaid
201207OtherWASHINGTON L&I
AKMD27931Medicaid
AKD48764Medicare UPIN