Provider Demographics
NPI:1417981093
Name:WHITAKER, DIANE BEASLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:BEASLEY
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:SATSKY
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4101 N ROXBORO ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2121
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:4101 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2121
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1697207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093G5Medicaid
NC89093G5Medicaid
NC2471178AMedicare ID - Type Unspecified
NCU74763Medicare UPIN