Provider Demographics
NPI:1407990740
Name:KLIVINGTON, DIANE (DO, MS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:KLIVINGTON
Suffix:
Gender:F
Credentials:DO, MS
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LAURA
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6902
Mailing Address - Country:US
Mailing Address - Phone:850-333-5113
Mailing Address - Fax:
Practice Address - Street 1:104 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6902
Practice Address - Country:US
Practice Address - Phone:850-333-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21472207V00000X
HI1313207V00000X
AL2094207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04674024Medicaid
MS479549YKDBMedicare PIN
MS04674024Medicaid