Provider Demographics
NPI:1417390709
Name:DAHER, DIAN KRYSTLE (DO)
Entity Type:Individual
Prefix:
First Name:DIAN
Middle Name:KRYSTLE
Last Name:DAHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:1906 SOUTHSIDE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1930
Practice Address - Country:US
Practice Address - Phone:904-724-3083
Practice Address - Fax:904-727-9103
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS17013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111327100Medicaid