Provider Demographics
NPI:1417361403
Name:PRLJEVIC, DIANA (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PRLJEVIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1919
Mailing Address - Country:US
Mailing Address - Phone:317-669-2312
Mailing Address - Fax:
Practice Address - Street 1:19 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1919
Practice Address - Country:US
Practice Address - Phone:317-669-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003850A152W00000X
OH6310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003850BOtherDRUG LEGEND CERTIFICATE NUMBER
OH6310OtherSTATE LICENSE
IN18003850AOtherSTATE LICENSE